Form DD-099D FORFF "Pre-pas Screening Tool for Members at Least 12 Years Old" - Arizona

What Is Form DD-099D FORFF?

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-099D FORFF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form DD-099D FORFF "Pre-pas Screening Tool for Members at Least 12 Years Old" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DD-099D FORFF (03-18)
Page 1 of 2
Division of Developmental Disabilities
Pre-PAS Screening Tool
FOR MEMBERS AT LEAST 12 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 Medical Diagnosis Information
Check the diagnosis(es) that the member currently has:
Autism
Intellectual Disability
Cerebral Palsy
Epilepsy (Seizures)
NOTE: Having one of the above diagnoses does not automatically qualify a person for ALTCS.
Member’s Independent Living Skill (ILS) Information
Check areas in which the member is currently receiving hands-on assistance from another person:
Eating/Drinking (may also check this if tube fed)
Bathing/Showering
Dressing (does not need to be able to match colors or choose clothing based on the weather)
Personal Hygiene ((includes hair care (not styling), brushing teeth, washing face and hands, shaving, nail care, menses
care and use of deodorant))
Preparing a simple meal at least 5 times weekly (e.g.,cereal, hot dog, eggs, frozen meals, sandwiches)
Toileting (i.e., indicating need to use the toilet, wiping, flushing, clothing adjustment)
Check areas in which the member has significant delays:
Hand Use: uses a raking motion or grasps with whole hand, unable to use fingers independently 
Walking ((unsteady 10-20 feet (with/without devices) alone or with another person; or doesn’t walk))
Understanding and following routines; only knows certain things happen at morning/noon/night
Member’s Behavior Information
Physically attacks other people (not animals) and must be stopped to prevent injury OR has caused someone serious
injury requiring medical attention in the past year
Verbally/physically threatens self/others/objects and causes fear at least once weekly, and requires intervention to stop
it or prevent it
Hurts self on purpose repeatedly at least once weekly causing injury and needing intervention to stop or prevent it from
happening OR has caused him/herself serious injury requiring medical attention in the past year
Disrupts self or others inappropriately at least once weekly and requires intervention to stop
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
See page 2 for EOE/ADA/LEP/GINA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DD-099D FORFF (03-18)
Page 1 of 2
Division of Developmental Disabilities
Pre-PAS Screening Tool
FOR MEMBERS AT LEAST 12 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 Medical Diagnosis Information
Check the diagnosis(es) that the member currently has:
Autism
Intellectual Disability
Cerebral Palsy
Epilepsy (Seizures)
NOTE: Having one of the above diagnoses does not automatically qualify a person for ALTCS.
Member’s Independent Living Skill (ILS) Information
Check areas in which the member is currently receiving hands-on assistance from another person:
Eating/Drinking (may also check this if tube fed)
Bathing/Showering
Dressing (does not need to be able to match colors or choose clothing based on the weather)
Personal Hygiene ((includes hair care (not styling), brushing teeth, washing face and hands, shaving, nail care, menses
care and use of deodorant))
Preparing a simple meal at least 5 times weekly (e.g.,cereal, hot dog, eggs, frozen meals, sandwiches)
Toileting (i.e., indicating need to use the toilet, wiping, flushing, clothing adjustment)
Check areas in which the member has significant delays:
Hand Use: uses a raking motion or grasps with whole hand, unable to use fingers independently 
Walking ((unsteady 10-20 feet (with/without devices) alone or with another person; or doesn’t walk))
Understanding and following routines; only knows certain things happen at morning/noon/night
Member’s Behavior Information
Physically attacks other people (not animals) and must be stopped to prevent injury OR has caused someone serious
injury requiring medical attention in the past year
Verbally/physically threatens self/others/objects and causes fear at least once weekly, and requires intervention to stop
it or prevent it
Hurts self on purpose repeatedly at least once weekly causing injury and needing intervention to stop or prevent it from
happening OR has caused him/herself serious injury requiring medical attention in the past year
Disrupts self or others inappropriately at least once weekly and requires intervention to stop
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
See page 2 for EOE/ADA/LEP/GINA disclosures
DD-099D FORFF (03-18)
Page 2 of 2
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, please discuss with the family that it is not appropriate to
submit a new ALTCS referral at this time.
Member’s Referral Summary
An ALTCS referral seems appropriate if the member has either:
At least 5 ILS boxes checked
OR a combination of ILS boxes with Behaviors equaling at least 6 boxes total
OR a Moderate or Severe Intellectual Disability with at least any 4 boxes checked.
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 (e.g., 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.
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