5. Records indicate the person is mentally retarded / developmentally disabled (MR /DD) or is dually-diagnosed with MI (MR / DD / MI). 6. PASARR / MI Level II assessment is deferred until the individual is able to participate in the assessment. (Explain the reason.) The NF is responsible to monitor the individual's condition and make a referral to the CMHC when the individual has sufficiently recovered to have a Level II. (Clearly explain reason for deferral and give any recommendations.) 7. D.
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How to fill out the IN State Form 47180 online
This guide provides a step-by-step approach to filling out the IN State Form 47180 online. The form is essential for documenting the decision regarding inappropriate referrals for the PASARR / MI Level II Mental Health Assessment. Whether you are familiar with digital forms or new to online submissions, this guide aims to support you through the process.
Follow the steps to complete the IN State Form 47180 online
- Click the ‘Get Form’ button to access the form and open it in the document editor.
- Fill in the identifying information for the applicant or resident, including their name in the format of last name, first name, middle initial, Social Security number or date of birth, and Medicaid number if applicable. Ensure the current physical address is accurate.
- Provide the name and address of the Community Mental Health Center (CMHC) responsible for the review, including the city of the CMHC's main office.
- Indicate the purpose of the referral by checking the appropriate box for PAS or ARR, and specify if the referral is routine or non-routine.
- Record the date the referral was received by the CMHC and check any applicable reason boxes that explain why the referral for a Level II assessment is considered inappropriate.
- Complete the CMHC certification section at the bottom of the form, including the reviewer’s signature, date, telephone number, and title or credentials.
- Finally, review the form for completeness and accuracy, then save the changes or use options to download, print, or share the completed form as necessary.
Complete your IN State Form 47180 online today for efficient processing.
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