TX HHS Form 1066. Transfer Request for PASRR DME and CMWC

The TX HHS Form 1066, Transfer Request for PASRR DME and CMWC, is a crucial document that facilitates the transfer of durable medical equipment (DME) or custom manual wheelchairs (CMWC) from one nursing facility to another. This form is specifically designed for nursing facility residents who have been identified as Preadmission Screening and Resident Review (PASRR) positive.

This form requires the completion of five sections: Resident and Legally Authorized Representative (LAR) Identifying Information, Discharging Nursing Facility (NF) Information, Admitting NF Information, Local Intellectual Developmental Disability (LIDDA) Authority Information, and Transfer Request for PASRR DME and CMWC. The admitting facility is responsible for submitting a "Receipt Certification" on the LTC Portal once the DME item or CMWC is delivered.

The form must be completely filled out to be accepted, and one form is required for each DME item or CMWC being transferred. Key points to note include:

• This form only applies to nursing facility residents who are PASRR positive.
• A separate form is needed for each DME item or CMWC being transferred.
• The admitting facility must submit a "Receipt Certification" on the LTC Portal once the equipment is delivered.