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If the answers are No to all of the above check No. DHMH 4345 Rev. 5/97 Name C. SERIOUS MENTAL ILLNESS MI see definitions Level of Impairment. DEPARTMENT OF HEALTH AND MENTAL HYGIENE PREADMISSION SCREENING AND RESIDENT REVIEW PASRR LEVEL I ID SCREEN FOR MENTAL ILLNESS AND MENTAL RETARDATION OR RELATED CONDITIONS NOTE This form must be completed for all applicants to nursing facilities NF which participate in the Maryland Medical Assistance Program regardless of applicant s payment source....
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