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Effective Date: 
6/2017

Documents

Form Instructions

Updated 6/2017

When to Prepare

This form is to be filled out by the service coordinator of a PASRR positive resident with ID/DD in a nursing facility (NF) who recently transferred prior to the receipt of authorized durable medical equipment (DME) or a custom manual wheelchair (CMWC).  This request will ensure the approval for the DME or CMWC is transferred to the admitting NF where the resident is currently living. The local intellectual and developmental disability authority (LIDDA) will be able to view the request on the TMHP LTC Portal, and therefore have access to all the information necessary to fill out this form.

Detailed Instructions

Section A:

Resident’s Name — Enter the first and last name of the resident for whom the request is being made.

Date of Birth — Enter the date of birth of the resident for whom the request is being made.

Resident’s Medicaid No. — Enter the Medicaid number of the resident for whom the request is being made.

Resident’s Social Security No. — Enter the social security number of the resident for whom the request is being made.

Document Locator Number (DLN) — enter the DLN number of the DME or CMWC request from the THMP LTC Portal.

Section B:

Discharging NF Name — enter the name of the NF from which the resident was discharged.

NF Contract No. — enter the contract number of the NF from which the resident was discharged.

NF Vendor number — enter the vendor number of the NF from which the resident was discharged.

Section C:

Admitting NF Name — Enter the name of the NF to which the resident is being/was admitted.

NF Contract No. — Enter the contract number of the NF to which the resident is being/was admitted.

NF Vendor No — Enter the vendor number of the NF to which the resident is transferring.

Admitting NF Address — enter the address of the NF to which the resident is being/was admitted

City, State, ZIP Code — Enter the city, state, and zip code of the NF to which the resident is being admitted.

Admitting NF Primary Contact Name — Enter the name of the person, who works for the NF, who can be contacted regarding the admission.

NF Area Code/Telephone No.— Enter the area code and telephone number of the primary contact with the admitting NF.

NF Area Code/Fax No. — Enter the area code and fax number of the admitting facility.

Section D:

Service Coordinator (SC) Name — Enter the name of the SC assigned to the resident, who is filling out this form.

Name of LIDDA — Enter the name of the Local Intellectual and Developmental Disability Authority (LIDDA) for which the SC works.

LIDDA phone number — Enter the phone number of the LIDDA for which the SC works.

LIDDA fax number — Enter the fax number of the LIDDA for which the SC works.

LIDDA Address — Enter the street and number of the LIDDA for which the SC works.

City, State, ZIP Code — Enter the street and number of the LIDDA for which the SC works.

Section E:

The SC needs to check the box corresponding to the type of service the transfer request is being filled out for. If the transfer is for a DME item, the SC must fill in the specific item that has been requested and will be transferred. The SC will enter the date the resident was admitted to the admitting facility. The SC will then sign this statement indicating the individual has an approval for DME or CMW which they have not received prior to the admission and would like that approval to be transferred to the admitting facility.

The SC will ask the admitting NF Administrator to acknowledge and sign Section F. of the form.  The SC will leave a copy of the signed form with the administrator.

Section F:

The Admitting NF administrator must sign to acknowledge the transfer of approval of DME and CMWCs. The administrator’s signature also indicates that they will make sure the facility’s therapist (or contractor) will ensure the DME item or CMWC meets the resident’s needs. Finally, the administrator’s signature indicates the facility will fax a “receipt certification” to the HHSC IDD PASRR unit at (512)438-2180 in order to generate a service authorization and draw down funds to pay the DME supplier.

Nursing facility administrators can obtain copies of the PASRR NF Specialized Services (NFSS) – CMWC/DME Receipt Certification form at www.tmhp.com

The SC will fax the completed 1066 form to:

IDD Services Preadmission Screening and Resident Review (PASRR) Unit

Attention: Program Specialist

Area Code and Fax No.: (512)438-2180

Additional questions, email PASRRSupport@hhsc.state.tx.us