PASRR Forms and Instructions

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.
  • 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.

  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 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.

  • Expedited Admission Process (PDF)
  • Exempted Hospital Discharge (PDF)
  • Preadmission Process (PDF)