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Effective Date: 




Updated: 5/2020



Form 1041 is used by a local mental health authority (LMHA) or local behavioral health authority (LBHA) provider to document a Preadmission Screening and Resident Review (PASRR) positive person’s refusal of PASRR mental illness (MI) specialized services.

When to Prepare

Form 1041 is prepared after an interdisciplinary team (IDT) meeting when a person who is eligible for PASRR MI specialized services refuses the specialized services recommended by the IDT.


The original completed form is maintained in the LMHA’s/LBHA’s permanent record for the person. A copy of the completed form is provided to the person or their legally authorized representative (LAR).


Detailed Instructions

LMHA/LBHA Name — Enter the name of the LMHA/LBHA.

LMHA/LBHA Contact — Enter the name of the LMHA/LBHA provider who attended the IDT meeting, confirmed the IDT on the PASRR Comprehensive Service Plan (PCSP) and is responsible for follow up with the person related to providing PASRR MI specialized services.

Area Code and Phone No. — Enter the area code and phone number for the LMHA/LBHA contact.

Person’s Name — Enter the name of the person who was evaluated PASRR positive and is eligible for PASRR MI specialized services and has refused to accept the specialized services.

PASRR Evaluation (PE) Document Locator No. — Enter the person’s Document Locator Number from the completed PE.

Name of Legally Authorized Representative (LAR) — Enter the first and last name of the person’s LAR, if one. Date of Nursing Facility Admission — Enter the date the person was admitted to the nursing facility.

Date of PE — Enter the date the person’s PE was entered into the Long Term Care online portal.

Date of Interdisciplinary Team (IDT) Meeting — Enter the date of the IDT meeting.

Benefits of Preadmission Screening and Resident Review (PASRR) Mental Illness (MI) Specialized Services — The LMHA/LBHA provider reviews the form with the person or their LAR. If assistance is requested, the LMHA/LBHA provider may need to read the form to the person.


Name of Person/LAR — Enter or print the name of the person who refused PASRR MI specialized services, which is either the person or LAR.

Person’s/LAR’s Signature and Date — The person or LAR signs and dates the form.

Name of LMHA/LBHA Provider — Enter the LMHA/LBHA provider’s name.

LMHA/LBHA Provider's Signature and Date — The LMHA/LBHA provider signs and dates the form.

LMHA/LBHA provider must list the PASRR specialized services recommended and describe the reason the person/LAR is refusing PASRR MI specialized services here — List the recommended specialized services and provide a brief description of the reason MI specialized services were refused. The LMHA/LBHA provider gives a copy of the completed form to the person/LAR.