REFERRAL FROM:
Contact: Phone #:
GENERAL INFORMATION:
Name of Applicant: Age:
Home Address:
DOB: Sex: male female Phone #: Marital Status: married single divorsed other
FINANCIALLY RESPONSIBLE PARTY:
Name: Relationship:
Address:
 Phone #: Home: Work:
Legal Authority:
Anyone appointed Power of Attorney,
 Guardian, and/or Health Care Proxy? Yes No
If so, who:
                   Power of Attorney               Guardian               Health Care Proxy
Additional Relative - Significant Other:

          Name                               Address                              Relationship   Telephone #

HOSPITALIZATIONS: (in last 60 days): Yes No
Name of Hospital: Date of Admission:
Name of Physician:
Primary Diagnosis: Secondary Diagnosis:
Physician to follow to facility: Phone #:
RESIDENT ACTIVITY HISTORY

Patient Name: Age:
Caregiver Name: Date:
Relationship: Years Known:

PREVIOUS NURSING HOME STAY: Within the last 60 days? Yes No
Name of Facility:
Contact: Phone #:
Medicare Days Used: Dates of Service: From To
Religion: Church:

TYPE OF PLACEMENT APPLICANT IS SEEKING:
Long-Term Short-Term Questionable Respite Care
Length of Stay: from to


**FINANCIAL INFORMATION**

Social Security #: Medicare #: Medex #:
Other Insurance:
Medicaid #: Date of Eligibility: (Pending Medicaid)
Application Submitted: Yes No Applied When?:
Applied Where?:
Name of Medicaid Agent and Telephone #:
Copy Available?: Yes No
If pending Medicaid, appointment made with
Business Office to review application:
Veteran or Spouse of a Veteran? Veteran Spouse of a Veteran Neither
Any other insurance that will cover nursing home care?:

          Name                         Address                               Insurance #       Telephone #
 

BURIAL ACCOUNTS:
Prepaid Funeral Arrangements: Yes No
Name of Funeral Home:
Address:

*****************************************************
I certify that I have fully investigated the applicant’s financial records and that this is a true and complete statement of the applicant’s current income and assets and any gifts or transfers for less than fair market value in excess of $1,000.00, that the applicant has made within the 36 months prior to the date of this application.

 
Applicant E-mail Address:
 
Responsible Party Signature Date:

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