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Filling out this form requires careful attention to detail. Ensure you understand each item before completing it. Follow each instruction carefully for accurate results.
How to fill out the Instruction Manual for SCREEN Form DOH-695?
1
Read the entire manual to understand the process.
2
Gather all necessary personal information and documents.
3
Fill out each section of the form accurately.
4
Review your entries for completeness and accuracy.
5
Submit the completed form as per the instructions.
Who needs the Instruction Manual for SCREEN Form DOH-695?
1
Individuals seeking admission to a residential health care facility.
2
Healthcare providers assisting patients with admission processes.
3
Social workers managing patient assessments.
4
Family members of patients requiring long-term care.
5
Patient representatives ensuring compliance with health regulations.
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What are the instructions for submitting this form?
To submit the SCREEN form, you may send it via email to healthdept@nyhealth.gov, fax it to (123) 456-7890, or mail it to the New York State Department of Health, 123 Health Street, Albany, NY 12345. Ensure all sections are completed and sign the document before submission. It is recommended to keep a copy for your records.
What are the important dates for this form in 2024 and 2025?
Keep an eye on relevant updates regarding the SCREEN form, especially those related to state regulations and deadlines for form submissions in 2024 and 2025.
What is the purpose of this form?
The SCREEN form is essential for evaluating a person's suitability for care outside a residential health facility. It ensures individuals are appropriately screened for mental health and other relevant conditions before placement. This helps in delivering tailored care to individuals based on their specific needs.
Tell me about this form and its components and fields line-by-line.
- 1. Identification: Details about the individual's demographics and background.
- 2. Direct Referral Factor For RHCF: Criteria assessing immediate needs for residential health care.
- 3. Dementia Diagnosis: Assessing for existing dementia and related conditions.
- 4. Level I Review: Initial evaluations for mental health and developmental disabilities.
What happens if I fail to submit this form?
Failure to submit this form may delay enrollment into necessary health services. Non-compliance can also lead to issues with Medicaid funding and treatment access.
- Delay in Care: Patients may experience delays in receiving essential healthcare services.
- Compliance Issues: Healthcare providers may face regulations conflicts and penalties.
- Funding Recoupment: Potential loss of funding from Medicaid if assessments are not completed.
How do I know when to use this form?
- 1. Pre-Admission Assessment: For individuals applying for admission to long-term care facilities.
- 2. Mental Health Evaluation: To determine the mental health status of applicants.
- 3. Compliance Requirement: To ensure that all assessments meet state regulations.
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