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Preadmission Screening
Submitter Information
Person Being Referred
Medical Information
ADL's
Admitting Nursing Facility
Submit
Results
Only staff at a hospital, clinic, hospice or nursing facility may submit the preadmission screening. The preferred submitter is the agency of the physician writing the nursing facility admission orders. Please complete all fields as accurately as possible. Once the data has been submitted, you will have the option to save or print the data fields for your records. See
Minnesota PAS Policy
for more information about preadmission screening.
Submitter Information
Submitter First and Last Name
Direct Phone Number
Please use the following format when entering a phone number: (xxx) xxx-xxxx
Extension
Alternate phone number during business hours if applicable
Please use the following format when entering a phone number: (xxx) xxx-xxxx
Email
Agency
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Is your Agency outside MN?
Agency Name
Service Type
Hospital
Clinic
Nursing Facility
Hospice
Street
Zip Code
City
County/State
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State
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SLL Referral
PAS
LOC Redetermination