TX HHS Form 1041. Refusal of PASRR Mental Illness Specialized Services

The Texas Health and Human Services (HHS) has issued Form 1041, Refusal of PASRR Mental Illness Specialized Services, for use by Local Mental Health Authorities (LMHAs) and Local Behavioral Health Authorities (LBHAs). This form is designed to document the refusal of specialized mental illness services for individuals admitted to a nursing facility. The purpose of this form is to inform individuals of their options and ensure they are aware of the benefits and availability of these services.

The form outlines the benefits of Preadmission Screening and Resident Review (PASRR) Mental Illness (Ml) Specialized Services, including providing persons with the necessary services and supports to improve quality of life, support community participation, and attain independence. It also explains that individuals have the right to self-determination and can accept or decline these services at any time.

This form is intended for use by LMHAs/LBHAs, Legally Authorized Representatives (LAR), and individuals admitted to a nursing facility. The issuing agency, Texas HHS, has developed this form to ensure that individuals are informed of their options and have the opportunity to make an informed decision about receiving PASRR MI specialized services.