Personal Care / Nursing Care Application for Admission

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Date

MM slash DD slash YYYY

Referred By

Application For

Personal Care

Nursing Care

Name of Applicant

First Middle Last Maiden

Date of Birth

MM slash DD slash YYYY

Present Address

Street Address City State / Province / Region ZIP / Postal Code Country

Telephone Number

U.S. Citizen or Lawful Permanent Resident?

Yes

Veteran of Military Services or Eligible to Receive Veterans Benefits?

Yes

If No, Where?

Social Security #

Medicare #

Medicaid # (if applicable)

Medicare Advantage

Attach copies of insurance cards, Front & Back Side

Medicare Card Upload (if applicable)

Drop files here or

Max. file size: 16 MB.

Date and Place of Birth

Marital Status

Single

Married

Widowed

Divorced

Veteran Of Military Service?

Yes

Name of Spouse

if applicable

Age of Spouse

if applicable

Date of Death(if widowed)

if applicable

Health Care Power of Attorney

Health Care Power of Attorney(s)

Name

Address

Relationship

Phone Number

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Financial Power of Attorney

Financial Power of Attorney(s)

Name

Address

Relationship

Phone Number

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Person Responsible For Payment of Bills

Person Responsible for Payment of Bills

Self

Financial Power of Attorney Listed Above

Other (Enter Details Below)

Name (if applicable)

Address

Relationship

Home/Work/Cell Phone

HAS A LIVING WILL/ADVANCE DIRECTIVE BEEN EXECUTED?

Yes

If Yes, Please Attach Copy of Document(s)

Living Will/Advanced Directive (If Applicable)

Drop files here or

Max. file size: 16 MB.

Name, Address and Telephone Number of Primary Physician

Name

Phone Number

Street

City, State, Zip Code

Medical Information

List Medical Information

Current Medical Problems/Diagnosis

Current Medications Being Taken

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Funeral Arrangements

Funeral Home Preferred

Address

Telephone

Specific Written Instructions for Autopsy, Donation of any Body Parts, Cremation, ETC.

Yes

If Yes, Who Has These Instructions?

Name, Address and Telephone Number of Person Responsible For Arrangements

Name

Telephone

Address

City, State, Zip

Living Situation

Past/Present Living Situation

Living Alone

With Spouse

Other

If 'Other', Name/Relation

Have You been a Resident In Any Other Home/Facility/Institution in the Last 60 Days?

Yes

If Yes - Date, Name and Address of Facility

Financial Statement

This Financial Statement is Part of the Application Process and Must Be Completed. Information Will Be Kept Confidential.

Assets

Money In Bank Or Elsewhere (Savings, Checking, CD's, Trusts, Annuities, ETC...) Please Indicate if JOINT Account.

Bank Account Information(Required)

Type of Account

Current Balance($)

Name Of Financial Institution

Joint Account Y/N

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Current Value of all Investments and Retirement Funds(Required)

Type of Account

Name of Investment Company

Current Value

Joint Account Y/N

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Other Assets

Description

Current Value

Joint Account Y/N

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Life Insurance Policies(Required)

Company

Policy #

Owner

Beneficiary

Cash Value

Face Value

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Real Estate - Total Value Of All Houses, Farms and Lots.(Required)

Residence Type

Location

Market Value

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Sources of Income

Monthly Amount Recieved For...

Social Security(Required)

Medicaid(Required)

Annuities(Required)

SSI(Required)

Pension(Required)

Other(Required)

Comments or Additional Information

Other Information

Name of Insurance Policy or Carrier for the following insurance coverages, if applicable.

Primary Health Insurance

If Applicable

Supplemental Insurance

If Applicable

Long Term Care Insurance

If Applicable

Burial Fund?

Yes

If Yes, Where Deposited?

If Yes, Amount ($)

Any Assets Transferred to Family or and Organization in the Last 5 Years?

Yes

If Yes, to Whom?

If Yes, When?

If Yes, What Amount?

Attach Additional Financial Information if Necessary

Drop files here or

Max. file size: 16 MB.

Consent(Required)

I affirm that the information provided in this application is true and correct to the best of my knowledge. Except as disclosed in this application, I affirm, to the best of my knowledge, that the applicant has not transferred any assets including, but not limited to, gifts for less than fair market value within the last five (5) years.

Applicant's Signature / POA Signature

Date

MM slash DD slash YYYY