Free 47178.pdf - Indiana

Transmit to FAXNET number:

INDIANA PAS/PASRR PROGRAM FAX COVER SHEET
State Form 47178 (R3 / 2-99) / BAIS 0025

State PASRR Unit: (317)233-2182 or (317)233-9135 OMPP: (317)233-8379

CONFIDENTIALITY NOTICE
The documents accompanying this telecopy transmission may contain confidential information. The information is intended only for use by the individual(s) or company named below. If you are not the intended recipient, you are notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this telecopied information is not permissible. If you have received this telecopy in error, please immediately notify us by telephone at the number below* to arrange for the return of the original documents. Thank you.

Date (month, day, year):

Time:

AM PM

Total number of pages (including this sheet):

TO:

FROM: (name of person to contact)

*Telephone number

( PASRR Program: MS21, FAMILY AND SOCIAL SERVICES ADMINISTRATION Bureau of Aging and In-Home Services 402 W. Washington St., W454 P Box 7083 .O. Indianapolis, IN 46207-7083 IPAS Only: MS07, FAMILY AND SOCIAL SERVICES ADMINISTRATION Office of Medicaid Policy and Planning 402 W. Washington St., W382 Indianapolis, IN 46204
Agency / Hospital (name, city)

)

Case name:

ALTERNATE FAX NUMBER: Enter FAX number to which determination form(s) should be faxed if different from FAX number at main office: ( )
Check one:

MI
Check one:

MR / DD or MI / MR / DD PAS - Rescreening

IPAS (non-PASRR)

PAS

Significant - Change RR only

RESIDENT At Home In Hospital In NF APS Admission Extension of PASRR Exempted Hospital Discharge Other: ___________

NONRESIDENT Indiana hospital patient Out-of-State hospital At Home Out-of-State NF Indiana NF (Hospital Direct after treatment in ER and acute care bed) Other________________________

NOTE:

Do not send in original or hard copy unless requested.

Please call this office to review this material:

As you requested:

Comments:

Signature of IPAS agency, CMHC or BDDS Ofc. representative completing this form

Identify: IPAS Agency number, BDDS Ofc., or CMHC

Date (month, day, year)

This packet was received at the State PASRR Unit. This packet was received at OMPP.
If a verbal determination is received, complete the information below as indicated:

Signature of representative of State PASRR Unit / OMPP

VERBAL APPROVAL

VERBAL DENIAL
Date approved or denied (month, day, year) Short-Term Approval: Enter number of days

Approved or denied by: (Name of State PASRR Specialist or Medicaid LOC Reviewer)