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Long Term Care

 
 

Woodland Haven /
Memory Care

 
     
 
 

Application for Admission

Important: Please complete in full.

Click here for a PDF version of the application that can be printed.

 

1.

First Name


Middle Name


Last Name


Age


Sex



2.

Date of Birth


Place of Birth

Maiden Name

3.

Present Location of Applicant

Phone Number

4.

Present Home Address



5.

Previous Home Address

   

6.

Current Marital Status (Select one)

Married
Single
Widowed
Divorced
Separated


 

Spouse Name

Spouse Address

Spouse Phone Number

7.

Nationality

Foreign Language Spoken


8.

Religion


Parish


Clergyman


9.

Veteran


Service Branch


Veteran Claim Number


10.

Physician's Name


Dentist's Name



11.

Facility Names & Dates

List in the space below, the names and exact dates of any hospitals or facilities (including nursing homes) you have stayed at in the past 120 days (4 months). Also include any periods you may have been at home.

Facility name(s), Dates from thru

12.

Medicare Number
Information will be collected later.

Medicare Effective Date
Information will be collected later.


13.

Medicaid Recipient Number
Information will be collected later.

 

14.

Social Security Number
Information will be collected later.

   

15.

Do you have health insurance?
Information will be collected later.

   

16.

US Citizen

How long in U.S.?

 

17.

In what county are you a resident?

How long?

 

18.

Registered Voter

YES
NO

Township where registered

 

19.

Funeral Home Desired
Information will be collected later.

Arrangements made?
Information will be collected later.

 

20.

Do you have an irrevocable Funeral Agreement?
Information will be collected later.

 

   

21.

Number of Children

   
 

Children Information:

For each enter:
Name, Age, Address, Telephone, Business Telephone

 

22.

Other Relatives or Interested Friends

For each enter:
Name, Age, Address, Telephone, Business Telephone

 

23.

METHOD OF PAYMENT
Check all that apply.

   
Medicare


  Medicaid  
Private Pay  
  Private Insurance  

24.

Are you receiving benefits from:
Check/Enter all that apply.

Social Security Benefits


Supplemental Security Income Benefits
Pension Benefits


Other Benefits

25.

IMPORTANT information concerning Resident Rights:
Does applicant have any of the following:

 

a.

LEGAL GUARDIAN

YES
NO

Is Legal Guardian court appointed?

YES
NO

If so, whom?
Enter Name, Address, Telephone, Date of Appointment


b.

DURABLE POWER OF ATTORNEY

YES
NO

 

If so, whom?
Enter Name, Address, Telephone, Date of Appointment


c.

PATIENT ADVOCATE DESIGNATION / DURABLE
POWER OF ATTORNEY FOR HEALTH CARE

YES
NO

 

If so, whom?
Enter Name, Address, Telephone, Date of Appointment


26.

Does applicant have an appointed person responsible for financial arrangements?

YES
NO

Are you officially appointed to this capacity?

YES
NO

If so, whom?
Enter Name, Address, Telephone, Date of Appointment


27.

Reason for Admission


28.

Does applicant accept idea of placement?

29.

Does the applicant currently smoke?

YES
NO

Does the applicant(resident) understand that they cannot smoke in the Facility or on the Facility property?

YES
NO



30.

Please indicate if you are interested in our memory care unit (Woodland Haven) for Alzheimer's disease and other related dementias:

YES
NO

31.

Person(s) to notify in case of emergency:

For each enter:
Name,  Address, Telephone



32.

Name of person who completed this application:

 

Relationship to Applicant




 

Date of Application




 

Admission Timeframe

Immediately
Within 3 months
Within 6 months
Within 12 months
Unknown at this time







       
 
 
 

Houghton County Medical Care Facility
1100 W. Quincy Street • Hancock, Michigan 49930

(906) 482-5050 tel

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