[Archived-not current] 2023 Christian Science Nursing Patient Admission Application

Patient Admission Application
Today's Date:

MonthDayYear
Date
Patient Information
First
Middle
Last
Street Address:
City:
State:
Zip Code:
Phone Number
Please enter a valid phone number
Date of Birth:

MonthDayYear
Date
Place of Birth:
Social Security No:
Please enter your Social Security Number
Medicare No.
Please enter your Medicare Number
Email Address:
example@example.com
Marital Status:

MarriedWidowedDivorcedSingle
Spouse Name:
Email:
example@example.com
Primary Phone Number
Other Phone:
Who should we contact if a need arises?
Primary Contact:
Name

First NameLast Name
Relationship:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email:
example@example.com
Secondary Contact:
Name

First NameLast Name
Relationship:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email:
example@example.com
Further Applicant Information: Member of The Mother Church?
Member of The Mother Church

YESNO
Member of a branch church?

YESNO
If not a member, how long have you been studying Christian Science?
Individuals come to The Leaves for healing. A Christian Science Journal-listed Christian Science practitioner must prayerfully support each patient of The Leaves every day.
Christian Science Journal-listed Christian Science Practitioner

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Listed in:
City, State
Christian Science Nursing Needs

In order to properly plan for your care, we ask that you provide information as to what Christian Science nursing services you believe would be necessary and/or helpful to you.
Nature of difficulty:
Bandaging assistance
Walking
Getting dressed
Reading
Bathing
During the night
Eating
Have you had any medical or psychological treatment within the last three (3) years?

YESNO
Please summarize the treatment:
Power of Attorney for Health Care

Federal law requires us to inform you that you have the right to execute a Power of Attorney for Health Care. You are under no obligation to execute a Power of Attorney for Health Care to stay at The Leaves. If you choose to draw up such a document, it is advisable to seek legal counsel.
Do you have a Power of Attorney for Health Care?

YesNo
If indicating yes, please fill in below and provide copy of documentation.
Name:
Street Address:
City:
State:
Zip Code:
Primary Phone:
Secondary Phone:
Email Address:
example@example.com
Financial Information
Invoices for services should be submitted to:
Name
Street Address:
City:
State:
Zip Code:
Phone:
Payments for Christian Science nursing care will be in what form? Please check one below:

CashCheckCredit Card (AMEX, MasterCard, Visa)
The Leaves will provide you with detailed invoices for services on a semi-monthly basis. Patients who expect that their insurance policies will cover the services are still required to pay The Leaves within 30 days of the date of invoice. Please contact our Financial Manager if you have questions.
Insurance Company Name:
Policy Number:
Insurance Company Address:
Financial Power of Attorney
Do you have a Financial Power of Attorney?

YesNo
If indicating yes, please fill in below and provide copy of documentation.
Name:
Street Address:
City:
State:
Zip Code:
Primary Phone:
Secondary Phone:
Email Address:
example@example.com
Acknowledgements
1. I acknowledge that admission to The Leaves is made only after the approval of the Director of Christian Science Nursing Services and the Executive Director.

2. I understand that each admission to The Leaves is for the purpose of healing. I understand that patients may be moved within the facility to best achieve this purpose. If The Leaves is unable to provide the level of care required to support healing, I acknowledge that the administration may ask the patient or agent to explore alternative care options beyond The Leaves.

3. In consideration of others, The Leaves may not be able to admit patients with diagnosed or suspected communicable or infectious diseases. I acknowledge that in these cases the administration may recommend Christian Science nursing care in the home. Specific situations will be individually considered. I acknowledge by my signature below that I understand The Leaves' policies regarding communicable or infectious diseases.

4. I understand that Christian Science nursing care will be provided in all cases where it supports healing. Healing and transformation are the prime considerations for admission. However, I agree to complete an insurance coverage / financial capabilities assessment with this application to identify financial needs that may require my attention in the future. (Please contact the Financial Manager if you have questions

5. I acknowledge that I remain personally responsible for the payment of all invoices submitted to me for Christian Science nursing services at The Leaves. In the event that insurance payments are not sufficient to cover invoiced services and that my personal financial resources prevent me from paying invoices in full, the following individual has agreed to pay remaining invoices in full and/or secure agreements of benevolence in order to meet that obligation.
Patient Signature

Clear
I, the undersigned, have agreed to be responsible for payment of invoices according to their terms of Christian Science nursing services at The Leaves and/or for securing agreements of benevolence in order to meet those obligations once the conditions of item number 5 above occur with respect to the patient.
Name:
Relationship to Patient:
Street Address:
City:
State:
Zip Code:
Phone:
Email:
example@example.com
Signature:

Clear
Date:

MonthDayYear
Date
Further Acknowledgments
Acknowledgment of receipt of "Patient Bill of Rights"

I have received a copy of "Patient Bill of Rights."
Patient Initial
Acknowledgment of receipt of "Patient Privacy Information"

I have received a copy of The Leaves, Inc. "Patient Privacy Information" effective April 14, 2003.
Patient Initial
Acknowledgment of receipt of "Christian Science Nurse Scope of Services"

I have received a copy of "Christian Science Nurse Scope of Services" effective April, 2011.
Patient Initial
Acknowledgment of Policy Regarding Personal Property

Although The Leaves will do its best to see that belongings are properly cared for while guests are here, we cannot guarantee their safety. We recommend that valuables not be brought to The Leaves. If necessary, small valuables such as credit cards, or cash, or jewelry (such as a ring) may be placed in the office safe on request to the Director of Christian Science Nursing Services. Your initials below signify that you understand The Leaves' policy regarding personal property.
Patient Initial
If a guest provides any of their own mobility aids (e.g., wheelchair, walker, etc.) or, audio equipment (e.g., cassette player, radio, headphones, etc.), please list the items below:
Request for Side Rails to Enhance Mobility

I request the use of the side rails on my bed to assist with mobility (as an enabling device
Patient Initial
I request admittance to The Leaves.
I understand and agree to abide by all sections of this document.
Signature of Applicant

Clear
Date

MonthDayYear
Date
Signature of person filling out application

Clear
Date

MonthDayYear
Date
Printed Name of person filling out application
Date

MonthDayYear
Date
Consent of Health Care Power of Attorney (if invoked)
Printed Name
Signature

Clear
Date

MonthDayYear
Date
Recommend approval of admission:
Director of Christian Science Nursing
Date

MonthDayYear
Date
Executive Director
Date

MonthDayYear
Date
Should be Empty:

Patient Admission Application

Patient Information

Power of Attorney for Health Care

Financial Information

Financial Power of Attorney

Acknowledgements

Further Acknowledgments