Note: The forms links are to blank PDF forms. All information recorded on paper forms must be data entered into the TMHP LTC Online portal.
- PASRR Level I Screening Form (PDF) — This form is completed for every person seeking admission to a Texas Medicaid nursing facility, regardless of their funding source.
- Detailed Item by Item Guide for completing the PL1 Screening Form) (PDF) — This document contains complete step-by-step instructions for local authorities and nursing facilities on when and how to submit the PL1 and IDT.
- Detailed Item by Item Guide for completing the PL1 Screening Form (Referring Entities) (PDF) — This document provides complete step-by-step instructions for referring entities on when and how to submit the PL1.
- PASRR Evaluation Form (PDF) — This form is completed to confirm the suspicion that a person has a mental illness, an intellectual disability or a developmental disability.
- Detailed Item by Item Guide for Completing the PASRR Evaluation (PDF) — This document provides step-by-step instructions on when and how to submit the PE.
- Detailed Item by Item Guide for Completing the PASRR Comprehensive Service Plan (PCSP) Form (PDF) — This document provides instructions to Nursing Providers and Local Authorities for completing the PASRR Comprehensive Service Plan form (PDF).
- Expedited Admission Categories (PDF) — This table is a list of the seven categories of admission that do not require the PE to be completed before admission. If a person is admitted under one of the seven listed categories, the PE is conducted by the LIDDA after admission.
- Detailed Item by Item Guide for Completing the Authorization Request for PASRR NFSS Form (PDF) —– This document contains complete step-by-step instructions for completing the Authorization Request for PASRR Nursing Facility Specialized Services form.
Companion Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (PDF) — This guide is to be used in conjunction with the Texas Medicaid & Healthcare Partnership (TMHP) Long-Term Care (LTC) Preadmission Screening and Resident Review User Guide which is available for downloading at tmhp.com to navigate the authorization request for PASRR Nursing Facility Specialized Services Form on the TMHP Long-Term Care Online Portal.
Approved Diagnostic Codes
Approved Diagnostic Codes for People with Related Conditions list (PDF) — The list is subject to change; use the link to access the most up-to-date list of approved diagnoses when completing the TMHP forms. The following diagnostic codes are found in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), 2019, and are recognized by the Health and Human Services Commission as conditions which might qualify a person as having a related condition as described in federal and state law.
PASRR Admission Flow Charts
Note: The flow chart details the process and requirements for each PASRR admission type.