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.

Place of Birth:

Middle Name:

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.

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 (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?

(B) DURABLE POWER OF ATTORNEY:

Yes
No

If so, whom?

(C) PATIENT ADVOCATE DESIGNATION / DURABLE
POWER OF ATTORNEY FOR HEALTH CARE

Yes
No

If so, whom?

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?

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

 

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