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Admission Application

- Admission
  - Admission Application

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- Personal Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Date of Birth: Please enter valid data.
  
  Age Please enter valid data.
  
  Previous Occupation Please enter valid data.
  
  Education Please enter valid data.
  
  Place of Birth Please enter valid data.
  
  US Citizen Yes No
  
  Home Address Please enter valid data.
  
  City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
  
  Marital Status Please enter valid data.
  
  Spouse's Name Please enter valid data.
  
  Religion Please enter valid data.
  
  Place of Worship Please enter valid data.
  
  Father's Name Please enter valid data.
  
  Mother's Maiden Name Please enter valid data.
  
  Referred to Sacred Heart Home by Please enter valid data.
  
  Applicant today is at Home Hospital Nursing Home Other
  
  Name of Facility Please enter valid data.
  
  Facility Phone Please enter valid data.
  
  Full Address of Facility Please enter valid data.
  
  Any Prior Admissions to a Nursing Home? Yes No
  
  If Yes, Name of Facility Please enter valid data.
  
  If Yes, Address of Facility
  
  If Yes, Dates of Admission Please enter valid data.
  
  Is applicant aware of the Placement Decision Yes No
  
  Personal Physician's Name Please enter valid data.
  
  Personal Physician's Address
  
  Personal Physician's Telephone Maximum 20 characters Please enter a phone number.
  
  Personal Physician's Fax Please enter valid data.
- Individual Responsible For Paying Bill
  
  (Please note: This is usually not the applicant, but rather the family, power of attorney, or other who has access to the funds of the applicant.)
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Applicant Please enter valid data.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Additional Relatives / Contacts
  
  Name Please enter valid data.
  
  Relationship to Applicant Please enter valid data.
  
  Address Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Power of Attorney / Advance Directives
  
  Has anyone been appointed Power of Attorney or Guardian? Yes No
  
  If so, who? Please enter valid data.
  
  To what extent? Please enter valid data.
  
  Has an Advance Directives been prepared? Yes No
  
  Has a Living Will been prepared? Yes No
- Financial Information Concerning Applicant:
  
  Medicare Number Please enter valid data.
  
  Part A Part B
  
  Private Insurance (B/C, B/S, AARP, etc.) Please enter valid data.
  
  Policy Number Please enter valid data.
  
  Other Insurance Please enter valid data.
  
  Policy Number Please enter valid data.
- Monthly Income of Applicant
  
  Social Security Please enter valid data.
  
  Military or Railroad Retirement Please enter valid data.
  
  Civil Service Retirement Please enter valid data.
  
  Other (specify) Please enter valid data.
  
  Pension Please enter valid data.
- Cash Assets in Banks, Credit Unions, Savings, and Financial Institutions
  
  Institution Name Please enter valid data.
  
  Location Please enter valid data.
  
  Type of Account Please enter valid data.
  
  Balance in Account Please enter valid data.
  
  Names listed on Account Please enter valid data.
- Real Estate Assets
  
  Does the applicant own their home? Yes No
  
  If yes, approximate value Please enter valid data.
  
  Is the property jointly owned? Yes No
  
  If yes, name of co-owners Please enter valid data.
  
  Does the applicant own any additional real property? Yes No
  
  If yes, approximate value Please enter valid data.
- Life Insurance
  
  Does the applicant have life insurance policies with cash value? Yes No
  
  If yes, company name Please enter valid data.
  
  Approximate cash value Please enter valid data.
  
  Annuities Please enter valid data.
- Other Assets / Investments (stocks, bonds, IRA's)
  
  Company Name Please enter valid data.
  
  Approximate Value Please enter valid data.
- Funeral Arrangements
  
  Has pre-paid funeral arrangements been made for applicant? Yes No
  
  Funeral Home Preference (name) Please enter valid data.
- Medicaid
  
  Has application for medical assistance been completed on behalf of the applicant? Yes No
  
  Medicaid Number: Please enter valid data.
  
  If applicant has applied, what was the date Please enter valid data.
  
  If applicant has applied, what county Please enter valid data.
  
  Dept. of Social Services Representative, if known Please enter valid data.
  
  Representative's Telephone Please enter valid data.
  
  If the perspective resident is eligible for Medicaid and is admitted to the hospital, will you pay the private pay room rate of $415 to hold the resident's bed? Yes No
- Additional Comments
  
  Additional Comments
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