All 6 items in Section 3, Screening Criteria, must be completed.
Preadmission or Hospital Exempted Discharge: the referral source completing the Level I Screening must provide a copy to the proposed nursing facility prior to admission.
Annual review: this form must be completed by the nursing facility annually.
Completion: it is voluntary, however, if NOT completed, Medicaid will not reimburse the nursing facility.
Current diagnosis: a clinician has established a diagnosis of a mental disorder within the past 24 months.
Psychotropic medications: medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior.
| Question | Answer |
|---|---|
| Form Name | DCH-3877 |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 56 |
| Avg. time to fill out | 10 min |
| Edition | Rev 8-25 |
| Issuing agency | Michigan Department of Health and Human Services |
| Other names | DCH-3877, DCH 3877, 3877 form, Michigan 3877 form, Level I Screening, PAS/ARR |
| Official source | DCH-3877 (Rev 8-25), Michigan Department of Health and Human Services |
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