Personal Care PAS

State of West Virginia Medicaid

Personal Care
Pre-Admission Screening (PAS)

PAS ID:
PAS Type:
PAS Status:
In Use By:
Offline Checkout:
Offline Checkout:

Submit By:
Submit Date:
Assessment Completed By:
Assessment Completion Date:

Physician Recommendation

35. Prognosis

Other:

36. Rehabilitative Potential

37. Diagnosis:

a. Primary:

Add Secondary Diagnosis

d. Other medical conditions requiring services:

Diagnosis Comments:

Diagnosis Comments

39. To the best of my knowledge, the patient's medical and related needs are essentially as indicated above (MUST be signed by M.D. or D.O.).

Physician Signature

Physician Credentials

Date Assessment Completed

Checking this box certifies that the MD/DO Name typed into the "Physician Signature" field above is the Physician who completed the PAS form. Also checking this box certifies that #39 of this PAS form will be completed with the MD/DO signature for this applicant and is on file in the applicant's record.

Physician's Address:

RN Signature

Signature Date

PC PAS 1.1.3.5