Application for Admission

Application for Admission
Applicant Information
Name of Applicant
Phone Number
Address

Address

Street Address Line 2

CityState / Province

Zip
Birthdate

MonthDayYear
Date
Age
Birthplace
SS No.
Applicant Medicare, Medicaid, and/or Insurance
Medicare No.
Medicaid No.
Is Medicare/Medicaid pending or active

PendingActive
Other Insurance
Group No.
I.D. No.
Marital Status
Religion
Parish
Responsible Party
Name
Address
Home Number
Work Number
Power of Attorney?

YesNo
Guardianship?

YesNo
Name
Notify in Case of Emergency
Name
Address
Home Number
Work Number
Relationship
Send Bill To
Name
Address
Home Number
Work Number
Attending Physician
Name
Address
Home Number
Work Number
Is Physician authorized to inform the Home as to the condition of applicant's health, treatment given and further treatment required or advisable?

YesNo
Applicant Medical Condition
Condition of Health
Is Applicant mentally competent?

YesNo
Senile or confused?
Is Applicant able to dress and attend to daily needs?

YesNo
Can Applicant come to the dining room for all meals?

YesNo
Does Applicant require the use of wheelchair or other aides?

YesNo
Type
Can Applicant walk outdoors unassisted?

YesNo
Can Applicant leave the premises unaccompanied?

YesNo
Does Applicant/Responsible Party understand that residence at Mount St. Joseph Rehab Center is subject to rules and requirements established and adjusted from time-to-time by the Administrator

YesNo
Has the Applicant executed any Advanced Directives?

YesNo
Advanced Directive type
(Power of Attorney for Healthcare/Living Will)
IN COMPLIANCE WITH TITLE VI, AN EQUAL OPPORTUNITY EMPLOYER, ADMISSIONS AND PRACTICES ARE CONDUCTED WITHOUT REGARD TO RACE, COLOR, AGE, GENDER, DISABILITY, CREED OR NATIONAL ORIGIN,
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Application for Admission

Applicant Information

Applicant Medicare, Medicaid, and/or Insurance

Responsible Party

Notify in Case of Emergency

Send Bill To

Attending Physician

Applicant Medical Condition