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Get HI DHS 1178 2013-2024

NUMBER: MEDICAID I.D. NUMBER: REFERRAL SOURCE: (Physician’s Name; Nursing Facility; Hospital; Etc.) LEVEL I SCREEN PART A: SERIOUS MENTAL ILLNESS (SMI): YES NO 1. ( ( Does the individual, currently meet the criteria for SMI? Must have a current diagnosis of a Major Mental Disorder, which is: a. A SCHIZOPHRENIC disorder, MOOD disorder, DELUSIONAL (PARANOID) disorder, PANIC OR OTHER SEVERE ANXIETY disorder, SOMATOFORM disorder, PERSONALITY disorder, or PSYCHOTIC disorder not elsewhere .

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