Form DD-099B "Pre-pas Screening Tool for Members at Least 2 Years 10 Months Old, but Less Than 6 Years Old" - Arizona

What Is Form DD-099B?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DD-099B by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

ADVERTISEMENT
ADVERTISEMENT

Download Form DD-099B "Pre-pas Screening Tool for Members at Least 2 Years 10 Months Old, but Less Than 6 Years Old" - Arizona

1016 times
Rate (4.5 / 5) 61 votes
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DD-099B FORFF (03-18)
Page 1 of 2
Division of Developmental Disabilities
Pre-PAS Screening Tool
FOR MEMBERS AT LEAST 2 YEARS 10 MONTHS OLD, BUT LESS THAN 6 YEARS OLD
Pre-PAS Guidelines
To be eligible for ALTCS, an applicant has a combination of factors that put the applicant at risk for being at an institutional
level of care (i.e., at risk of being in a nursing home [SNF] or an intermediate care facility).
Individuals in an intermediate care facility or SNF/ ICF-IID require treatment or rehabilitation in a protected residential
setting where they receive ongoing evaluations, planning, 24 hour supervision, coordination and integration of health or
rehabilitative services. These programs occur on a daily basis and require active treatment, which is an aggressive and
well coordinated program.
Individuals in this environment need more than the informal care characterized by verbal reminders, occasional physical
assistance or informal behavioral methods. In order to meet the ALTCS criteria, an individual must require a level of care
which is below that of an acute hospital setting, but above that of supervisory level of care.
Member’s Information
Name (Last, First, M.I.)
Date of Birth
Date Pre-PAS Completed
Member’s ALTCS Information
If the member has previously applied for ALTCS, what has changed for the member since then that is NOW putting
the member at risk of, or requiring, an institutional level of care? (Check all that apply)
Hospitalizations/ER Visits
New Diagnosis
Additional/New Treatments
Decline in Function
Placements in Facility
Additional/New Behaviors
If nothing has changed since the last ALTCS application, discuss with the family that it is not appropriate to submit
a new ALTCS referral at this time.
Member’s Independent Living Skill (ILS Information)
Check areas in which the member is currently receiving hands-on assistance from another person:
Walking/Running
Using an age-appropriate, recognizable language (i.e.,uses 2-3 word sentences)
Playing with other children (including siblings)
Using his/her thumb and fingers in opposition
Reaching for a familiar person when that person holds out his/her arm to him/her
Playing informal games (e.g.,hide-and-seek, jump rope, or catch)
Responding to his/her name when you call him/her
Brushing his/her teeth, wash his/her own hands
Pulling up clothing that has an elastic waistband
Following multi-step directions (e.g.,“Go get that toy and put it in the toy box”)
Following “If-then” instructions (e.g.,“If you pick up your room then you can play outside”)
Being toilet trained (partially or fully)
Member’s Behavior Information
Does things over and over and can’t seem to stop himself/herself (e.g.,rocking, hand flapping).
Cries, screams, demands attention, teases/pesters others, or has tantrums at least once weekly and needs an intervention
to stop.
Hurts him/herself deliberately (e.g., forcibly bangs his head, slaps him/herself) causing injury and needing an intervention
to stop
Destroys or damages items on purpose
Stares at nothing, or wanders with no purpose
Physically attacks other people without provocation
See page 2 for EOE/ADA/LEP/GINA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DD-099B FORFF (03-18)
Page 1 of 2
Division of Developmental Disabilities
Pre-PAS Screening Tool
FOR MEMBERS AT LEAST 2 YEARS 10 MONTHS OLD, BUT LESS THAN 6 YEARS OLD
Pre-PAS Guidelines
To be eligible for ALTCS, an applicant has a combination of factors that put the applicant at risk for being at an institutional
level of care (i.e., at risk of being in a nursing home [SNF] or an intermediate care facility).
Individuals in an intermediate care facility or SNF/ ICF-IID require treatment or rehabilitation in a protected residential
setting where they receive ongoing evaluations, planning, 24 hour supervision, coordination and integration of health or
rehabilitative services. These programs occur on a daily basis and require active treatment, which is an aggressive and
well coordinated program.
Individuals in this environment need more than the informal care characterized by verbal reminders, occasional physical
assistance or informal behavioral methods. In order to meet the ALTCS criteria, an individual must require a level of care
which is below that of an acute hospital setting, but above that of supervisory level of care.
Member’s Information
Name (Last, First, M.I.)
Date of Birth
Date Pre-PAS Completed
Member’s ALTCS Information
If the member has previously applied for ALTCS, what has changed for the member since then that is NOW putting
the member at risk of, or requiring, an institutional level of care? (Check all that apply)
Hospitalizations/ER Visits
New Diagnosis
Additional/New Treatments
Decline in Function
Placements in Facility
Additional/New Behaviors
If nothing has changed since the last ALTCS application, discuss with the family that it is not appropriate to submit
a new ALTCS referral at this time.
Member’s Independent Living Skill (ILS Information)
Check areas in which the member is currently receiving hands-on assistance from another person:
Walking/Running
Using an age-appropriate, recognizable language (i.e.,uses 2-3 word sentences)
Playing with other children (including siblings)
Using his/her thumb and fingers in opposition
Reaching for a familiar person when that person holds out his/her arm to him/her
Playing informal games (e.g.,hide-and-seek, jump rope, or catch)
Responding to his/her name when you call him/her
Brushing his/her teeth, wash his/her own hands
Pulling up clothing that has an elastic waistband
Following multi-step directions (e.g.,“Go get that toy and put it in the toy box”)
Following “If-then” instructions (e.g.,“If you pick up your room then you can play outside”)
Being toilet trained (partially or fully)
Member’s Behavior Information
Does things over and over and can’t seem to stop himself/herself (e.g.,rocking, hand flapping).
Cries, screams, demands attention, teases/pesters others, or has tantrums at least once weekly and needs an intervention
to stop.
Hurts him/herself deliberately (e.g., forcibly bangs his head, slaps him/herself) causing injury and needing an intervention
to stop
Destroys or damages items on purpose
Stares at nothing, or wanders with no purpose
Physically attacks other people without provocation
See page 2 for EOE/ADA/LEP/GINA disclosures
DD-099B FORFF (03-18)
Page 2 of 2
Member’s Medical Diagnosis Information
Check the diagnosis(es) that the member currently has:
Autism
Intellectual Disability
Cerebral Palsy
Epilepsy (Seizures)
OR is “At Risk” for at least one of the above diagnosis
NOTE: Having one of the above diagnoses does not automatically qualify a person for ALTCS.
Member’s Referral Summary
If the child has 8 or more checked boxes in the ILS area,
OR
a combination of ILS boxes with Behaviors totaling at least 8 boxes, an ALTCS referral should be considered.
If member meets criteria above, Date ALTCS Referral sent:
Include the Member’s current records with this referral to ALTCS:
Most Recent Medical Records (e.g.,PCP, specialists)
Most Recent School Records (i.e.,IEP, therapy reports, evaluations)
Most Recent Behavioral Health Records
Testing provided for diagnosis(es)
Most Recent DDD ISP
DDD Employee completing this Pre-PAS:
DDD Employee Phone #:
DDD Fax#:
ALTCS Eligibility Outcome:
Eligible
Ineligible
Date of ALTCS Determination:
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. To request this document in alternative format or for further information about this policy, contact
the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language
assistance for DES services is available upon request. Disponible en español en línea o en la oficina local.
Page of 2