Deer Creek Healthcare Admissions Form

Welcome to Deer Creek Healthcare Admissions. This form is used to gather all of the information required to admit you, or a loved one, to our facilities. Please read each question carefully and fill out the form to the fullest of your knowledge. If you need more time, you can save your progress, and a link will be emailed to you so that you can continue the form at your convenience.

You will need the following documents for this form (you can also save your progress at the bottom and come back):

1. Driver's License or Social Security Card

2. Insurance ID Cards (If you have insurance)

3. Medicare and Medicaid Cards (If you have Medicare / Medicaid)

4. Primary Physician Information

Once you have completed your form, we may reach out to you to gather any missing information. Once all information has been gathered, you will receive completed forms for your review and signature via email through SignNow.

If you have any questions/issues, do not hesitate to reach us at admissions@deercreekhealth.com, or call (866) 219-3619.

We look forward to serving you!
Are You:

The Responsible Party for The ResidentThe Resident (You are your own responsible party)
Facility*
Which Facility Are You Submitting Information For?
Your E-mail Address*
We will use this to communicate with you and send final forms to sign.
Approximate Expected Admission Date

MonthDayYear
Expected Admission Month*
What Month Do You Expect Admission?
Expected Admission Day*
What Day Do You Expect Admission?
Expected Admission Year*
What Year Do You Expect Admission
- Your First Name*
- Your Last Name*
- Your Primary Phone Number*
  Best Number To Reach You By
- Your Home Phone Number
  If Applicable
- Your Work Phone Number
  If Applicable
- Your Phone Number
  
  Area CodePhone Number
- Your Primary Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Relation To Resident*
- Are You Power Of Attorney For The Resident?*
  
  YesNo
- Resident First Name*
- Resident Last Name*
- Gender*
  
  MaleFemale
- Resident Month Of Birth*
- Resident Day Of Birth*
- Resident Year Of Birth*
- Resident Phone Number
- Resident E-mail
- Resident Current Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Resident Social Security #*
- Please Verify Resident Social Security #*
  Enter Social Again To Avoid Mis-Match
- Is The Resident A Medicare Patient?*
  If resident has a Medicare number, select Yes.
- Medicare #
- Verify Medicare #
  Please enter resident's medicare number again
- Is The Resident A Medicaid Patient?*
  If resident has a Medicaid number, select Yes.
- Medicaid #
- Verify Medicaid #
  Please enter resident's medicaid number again
- Does The Resident Have A Primary Insurance Policy?*
  If resident has insurance, please select Yes.
- Primary Insurance Company
- Primary Insurance #
- Verify Primary Insurance #
  Please enter primary insurance number again
- Primary Insurance Group #
- Primary Insurance Type
- 1st Insurance Effective Month
- 1st Insurance Effective Day
- 1st Insurance Effective Year
- Primary Insurance Effective Date
  
  MonthDayYear
- Does The Resident Have A Secondary Insurance Policy?*
  If resident has a secondary insurance policy, please select Yes.
- Secondary Insurance Company
- Secondary Insurance #
- Secondary Insurance Group #
- Secondary Insurance Type
- 2nd Insurance Effective Month
- 2nd Insurance Effective Day
- 2nd Insurance Effective Year
- Secondary Insurance Effective Date
  
  MonthDayYear
- What Pharmacy Would You Like The Resident To Use?*
  If you select other, please enter the information below. *PLEASE NOTE ALL PHARMACIES MUST MEET OUR REQUIREMENTS, IF THEY DO NOT, WE WILL SUGGEST PHARMACIES OR USE PHARMCARE.
- Pharmacy Name
- Pharmacy Phone Number
- Pharmacy Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- What Room Type Would You Like?*
- Primary Care Physician Full Name*
- Physician Phone Number*
- Physician's Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Physician Address
- Physician City
- Physician State
- Physician ZIP
- Please identify up to three people who Deer Creek Healthcare may disclose limited protected health information to. These people can include family members, other relatives, or any person identified by you.
  
  This is purely optional, however, it allows us to identify people who are involved in the care of, or in the payment of, the residents of our facilities.
- HIPAA Person 1
- HIPAA Person 2
- HIPAA Person 3
- This explanation is for Bed Hold Policy Question below:
  
  If resident's stay is paid by Medicaid, and resident will be out of the facility on therapeutic leave or vacation, Medicaid will hold resident's bed for a maximum of 7 days. After that, you are responsible for costs associated with reserving the bed/room. If the leave is due to hospitalization, Medicaid will hold room/bed for up to 30 days, after that, you are responsible for costs.
- BED HOLD - If the resident is away / on leave from the facility for more than 30 day (hospitalized) or more than 7 days (vacation), would you like us to hold their room / bed?*
  
  YESNO
- Do you wish for our facility to perform laundry duties for the resident? (If answered no, laundry must be picked up every other day)*
  
  YESNO
- Would you like the resident to be allowed to go on scheduled outings with the facility? (scheduled in advance)*
  
  YESNO
- May we use photographs and/or video taken by our staff or team for social media purposes?*
  
  YESNO
- Would you like your loved one / the resident asked about returning to the community (leaving our facility) periodically?*
  
  YESNO
- If you answered yes, how often would you like them asked?
  
  Every YearEvery 3 Months
- Have You, or Resident Executed A DNR?*
  
  YESNO
- Have You, or Resident Executed An Advanced Directive?*
  
  YESNO
- Have You, or Resident Executed A Power Of Attorney?*
  
  YESNO
- Is there any other information that you would like to share with us?
- Please Upload Resident Driver's License or State ID Card
  
  Browse Files
  You may take a photo with your phone / camera and upload it to your computer if you need to. Or, if you are filling out via mobile, take a photo with your camera and upload. Cancelof
- Please Upload A Copy Of Resident's Primary Insurance Card
  
  Browse Files
  You may take a photo with your phone / camera and upload it to your computer if you need to. Or, if you are filling out via mobile, take a photo with your camera and upload. Cancelof
- Do you agree to submit to Deer Creek Healthcare your information and the information on this form for the purposes of admission of you, or the Resident that you represent, to one of our long term healthcare facilities? You also agree that you understand you will be contacted by our team members to attain any missing information, and that your information will only be used internally by our facility staff.*
  
  Yes, I agree / Understand
- Please verify that you are human*
- Should be Empty: