The forms needed by Long Term Care providers are accessible on this website or through the DADS website. Click on the following links to download the forms.

• 1290 - NPI Long Term Care Form
• Instructions 1290- Long Term Care Claim Form
• 3071-Recipient Election/Cancellation/Discharge Notice
• 3074-Physician Certification of Terminal Illness Notice
• Nonemergency Ambulance Prior Authorization Request

Nursing Facility

• 3618 - Resident Transaction Notice
• 3618 – Resident Transaction Notice Instructions
• 3619 – Medicare / SNF Patient Transaction Notice
• 3619 – Medicare / SNF Patient Transaction Notice Instructions
• Federal MDS 2.0 Assessments(CMS)
• Federal MDS 2.0 Assessment Instructions
  refer to RAI User's Manual then RAI Chapter 3
• Federal MDS 2.0 Assessment Schedule for RAI  
  refer to RAI User's Manual then RAI Chapter 2
• Federal MDS 3.0 Assessments (CMS)
  refer to MDS 3.0 Item Subsets
• Federal MDS 3.0 Assessment Instructions
  refer to RAI User's Manual then RAI Chapter 3
• Federal MDS 3.0 Assessment Schedule for RAI  
  refer to RAI User's Manual then RAI Chapter 2
• LTCMI 2.0 – Nursing Facility
• LTCMI 2.0 – Nursing Facility Instructions
• LTCMI 3.0 – Nursing Facility
• LTCMI 3.0 – Nursing Facility Instructions
• PASRR Evaluation Form
• PASRR Evaluation Instructions
• PASRR Level 1 Screening Form
• PASRR Level 1 Screening Instructions for Local Authorities and Nursing Facilities
• PASRR Level 1 Screening Instructions for Referring Entities
• PASARR Screening Instructions (Inactive as of May 27, 2013)

Community Waiver Programs

• Medical Necessity and Level of Care 3.0 Assessment (updated 10/24/12)
• Medical Necessity and Level of Care 3.0 Assessment Instructions (updated  11/01/12)