RELEASE of INFORMATION Preadmission Screening and Resident Review (PASRR) Program And

RELEASE OF INFORMATION Preadmission Screening and Resident Review (PASRR) Program and Service Review Project

Individual’s Name (last, first) Last 4 digits: Soc. Sec. No. Birth date Gender

Address

PURPOSE Federal and State law requires that the State of Mississippi manage a process to review the physical and mental condition of nursing facility applicants and residents with indications of serious mental illness, mental retardation and related conditions. In order to make decisions about your admission or continued stay in a nursing home, or the types of services you may require while a resident of a nursing home, the Mississippi Division of Medicaid, Department of Mental Health and the local evaluator need to develop detailed information about your physical and mental condition. This Release of Information is voluntary with the understanding that the information requested will be kept confidential and will be used in connection with decisions related to admission to or continued stay in a nursing facility.

The Release of Information must be signed and dated but may be revoked at any time except to the extent action has been taken prior to revocation. This consent will expire ninety (90) days after you have signed and dated the form, or sooner, if you choose.

In addition to allowing us to collect information about your needs from agencies or individuals who have been involved in your health care in the past, your signature on this form also allows the Mississippi Division of Medicaid, Department of Mental Health and the local evaluator to provide a copy of a report containing information about your physical and mental condition and the outcomes of the review process to you, your legal guardian (if applicable), your physician, the admitting or retaining nursing facility, and, if you are seeking admission to a nursing facility from a hospital, the discharging hospital. Federal and State laws require that we send them this information and our decisions based on this information. Your consent to release information is valid for this purpose. This information and the release form have been prepared in accordance with the authority specified in Title 42 of the Code of Federal Regulations at Section 2.31, Part 2, Subpart C, as revised October 1,1985, and in accordance with 3701.243 of the Revised Code.

STATEMENT OF RELEASE I release the Mississippi DOM, DMH, and those named below from all legal responsibility and liability that may arise from the action I am authorizing.

I, the undersigned, hereby give my permission to: to release information from my medical record to the Mississippi DOM, DMH and the local evaluator. This authorization includes release of information concerning treatment, hospitalization, and/or outpatient care for any medical condition, including psychological or psychiatric impairment, drug abuse and/or alcoholism, sickle cell anemia, Acquired Immune Deficiency Syndrome (AIDS), and the results of any tests for antibodies to the Human Immunodeficiency Virus (HIV). The following information may be released or reviewed. Discharge Summary Reports or Tests Consultation Reports Outpatient Clinic Notes History and Physical Other Progress notes I also give my permission to the Ascend and the local evaluator to provide information about my physical and mental condition and the outcomes of their determination to my legal guardian, physician, the admitting or retaining nursing facility, and, if I am seeking admission to a nursing facility from a hospital, the discharging hospital. Individual's Signature Date Signed

If individual is unable to sign, provide a reason (e.g., is a minor).

If individual cannot sign, signature of closest relative or legal guardian. Date Signed

I have read and fully understand the above statements as they apply to me. Return this form to: Ascend Management Innovations LLC, Attn: Mississippi PASRR Division: Fax 1-877-431-9568.

227 French Landing Drive, Suite 250, Nashville, TN 37228 | Phone: 877-431-1388 | Fax: 877-431-9568 | www.ascendami.com