Loading
Get Fl Agency For Health Care Administration Form 004 2017-2026
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the FL Agency For Health Care Administration Form 004 online
The FL Agency For Health Care Administration Form 004 is essential for conducting a preadmission screening for individuals with serious mental illness and/or intellectual disabilities seeking admission to a Medicaid-certified nursing facility. This guide provides clear and supportive instructions on how to accurately complete the form online.
Follow the steps to fill out the FL Agency For Health Care Administration Form 004 online
- Click ‘Get Form’ button to obtain the form and open it in the appropriate platform.
- Enter the individual’s demographics such as name, age, Social Security Number, and contact information on page 1. Ensure that all information is complete and legible.
- Check the box to indicate the individual’s current location at the time of screening, and provide details for the individual’s parent, guardian, or legal representative if applicable.
- If available, enter the Medicaid or other health insurance identification information. You may also list up to three nursing facilities for potential admission in the designated section.
- On page 2, write the name and date of birth of the individual at the top of the page.
- In Section I: PASRR Screen Decision-Making, review pertinent medical information and check the appropriate boxes for the history or suspicion of mental illness or intellectual disability. Provide additional diagnosis or conditions as needed.
- Complete the relevant questions in Section II concerning other indications for PASRR decision-making by checking ‘Yes’ or ‘No’ as appropriate for each question.
- In Section III, indicate whether the admission is provisional or under a hospital discharge exemption by selecting the applicable boxes and providing the completion date for any necessary evaluations.
- In Section IV, determine and check the box for whether the individual may or may not be admitted to a nursing facility, and complete the necessary fields for the person who completed the screen.
- Review the entire form for completeness, sign where required, and ensure distribution areas indicate where the Level I PASRR screen and accompanying documents must be sent.
Complete the FL Agency For Health Care Administration Form 004 online for efficient processing of preadmission screenings.