Texas PASRR Form 1012 available beginning Sept. 24

Ken BellClient News4 Comments

Texas Medicaid HHS form 1012

Attention Texas providers:

Texas Health and Human Services (HHS) has informed us that the new Form 1012 for will be available for use effective Sept. 24, 2018. Nursing Facilities that discover a mental illness diagnosis for an individual in their facility, when the current PASRR Level 1 screening is negative for MI, must use Form 1012 from Sept. 24 forward.

What is Form 1012?

Form 1012 assists Nursing Facilities (NF) in determining if a previously negative Preadmission Screening and Resident Review (PASRR) Level I (PL1) Screening form, that has already been submitted to the Long Term Care (LTC) Portal, needs to be changed to a positive PL1 for Mental Illness (MI). This form confirms if the individual meets the Code of Federal Regulations (CFR) definition of MI, if there is a dementia diagnosis  and if the individual’s dementia is the primary diagnosis. This form also provides NFs documentation for the medical record as to why a new positive PL1 was not completed.

How can I learn about Form 1012?

Training for this form was provided on Aug. 29, 2018 by via an HHS webinar hosted by SimpleLTC. If you missed the webinar, you can watch it on-demand and download the slides at the link below:




How can I access Form 1012?

You can find Form 1012 on the Texas Health and Human Services website at the link below:


Texas HHS asks that you please ensure all staff are aware of this change and have taken the training to be able to complete the form.

4 Comments on “Texas PASRR Form 1012 available beginning Sept. 24”

  1. I need the Fax number to send the 1012 form to for Comal County. Your help would really be appreciated.
    Thank you
    Alisa Doering

Leave a Reply

Your email address will not be published. Required fields are marked *