MS Reassessment Screening Form

Return this completed form to Ascend via fax at 877-431-9568, Attn: Mississippi Team.

An Ascend Mississippi Team Member will schedule a call to go over the information in this form with you. Be sure to provide your name, facility, and contact information at the bottom of the form.

First Name: Middle Initial: Last Name:

Social Security #: -- Date of Birth: Marital Status: M S W D

Medicaid ID #: Gender: M F

Pay Source: Private Pay/Insurance Medicare Medicaid Medicaid pending Dual Medicare/Medicaid

Legal Representative Name: Phone #: -- Fax #: --

Address: City: State: Zip:

Legal Representative Type: Court-appointed Guardian/Conservator POA Other:

  1. Is this individual currently a resident in your facility? Yes No
  2. If yes to 1, is s/he potentially discharging or transferring within the next month? Yes No
  3. If yes to 1a, identify the estimated discharge/transfer date:
  4. If yes to 1a, identify the anticipated discharge/transfer location(specify facility name):
  5. If not discharging in the near future, in your opinion does s/he have the capacity to discharge to the community within the next 6 months? Yes No Unknown
  6. Does your facility have plans to discharge him/her within that time period? Yes No Unknown
  7. Does s/he continue to meet criteria for nursing facility level of care based on the DOM PAS application form (i.e., a PAS Score of 50 or above)? Yes No Unknown
  8. If the individual is not currently in your facility, where is s/he located at present? Choose the single best response.

Discharged to the community (e.g., home with family) / Transferred to an unknown nursing facility / Transferred to a known nursing facility (specify facility name):
Deceased / Temporary absence, expected to return on or around (specify date):
  1. Behavioral Health Stability:
  2. Is there any indication the individual poses a danger to self? Yes No
  3. Is there any indication the individual poses a danger to others? Yes No
  4. Is the individual exhibiting any symptoms of psychosis (e.g., hallucinations, delusions, etc)? Yes No
  5. If yes to 3a, 3b, and/or 3c, describe symptoms/behaviors:
  6. Is the individual receiving any of the following services from an external provider, such as a Mental Health Center?

Service / Yes / No / Unknown / Frequency
a.Medication evaluation and monitoring
b.Individual therapy
c.Family therapy
d.Group therapy
e.Psychosocial Rehabilitation

Provide your name and contact information so Ascend may reach you for follow up.

Name: Date: Phone:

Facility Name: Fax:

Please complete and fax to Ascend Mississippi Team at 877.431.9568
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