Christian Science Nursing Application for Care at The Leaves

APPLICATION AGREEMENT FOR STAYS AT THE LEAVES

FOR CHRISTIAN SCIENCE NURSING CARE PLEASE COMPLETE THE ENTIRE FORM. FOR REST & STUDY OR CREEKSIDE 2-WEEK TRIAL, COMPLETE THE FORM TO THE BLACK LINE.
Please place a checkmark in the appropriate box:

For Christian Science Nursing CareFor Creekside 2-Week TrialFor Rest & Study stays
Applicant Information
Today's Date

MonthDayYear
Date
Applicant's Full Name:
First
Middle
Last
Place of Birth
Date of Birth

MonthDayYear
Date
Street Address
City
State
Zip Code
Email Address
example@example.com
Primary Phone
Social Security No
Medicare No.
Marital Status - please check the appropriate box below:

MarriedWidowedSingleDivorced
Spouse Name (if applicable)
Spouse's Phone Number
Spouse's Email Address
example@example.com
Who do we contact if or when a need arises?
Name
Relationship
Phone Number
Please enter a valid phone number.
Street Address
City
State
Zip Code
Email
example@example.com
Are you a member of The Mother Church? Please type YES or NO
Type YES
Type NO
If not a member of The Mother Church, how long have you been studying Christian Science?
Are you a member of a branch church? Please type YES or NO
Type YES
Type NO
Because individuals come to The Leaves for healing, it is our policy that a current Journal-listed Christian Science practitioner prayerfully supports each patient of The Leaves every day.
Journal-listed Christian Science Practitioner or Teacher
Type First and Last Name and CS or CSB
Phone
Listed in
City and 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:
Walking
Type Yes or No
Reading
Type Yes or No
Bathing
Type Yes or No
Eating
Type Yes or No
Bandaging
Type Yes or No
Getting dressed
Type Yes or No
Needs assistance during the night
Type Yes or No
Have you had any medical or psychological treatment within the last three (3) years?
Type YES
Type NO
If YES, please summarize the treatment
HEALTH CARE POWER OF ATTORNEY

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.

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?

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:

The Leaves will provide you with detailed invoices for services on a 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 Business Manager if you have questions.

Please indicate payment method below:

Cash, Check or Credit Card (AMEX, MasterCard, Visa)
CASH
If this is the payment method, type an X here
CHECK
If this is the payment method, type an X here
CREDIT CARD (AMEX, MasterCard or VISA accepted)
If this is the payment method, type an X here
Insurance Company Name
Policy Number
Insurance Company Address
If you have a Financial Power of Attorney, please fill in the section below and provide a copy of documentation.
Name
Street Address
City
State
Zip Code
Primary Phone
Secondary Phone
Email Address
example@example.com
ACKNOWLEDGMENTS

1. I acknowledge that admission to The Leaves is made only after the approval from the Admission Committee.

2. I understand that Christian Science nursing care will be provided in all cases where it supports healing. Expectancy of healing and progress are the prime considerations for admission. 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 request the patient or agent to find another care option 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 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. 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 Business Manager if you have questions.
Acknowledged - 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 4 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
Acknowledgment of receipt of "Patient Bill of Rights."

Please click here for "Patient Bill of Rights" document.
Patient Initial
Initial above to acknowledge receipt of "Patient Bill of Rights" document.
Acknowledgment of receipt of "Patient Privacy Information."

Please click here for "Patient Privacy Information document.
Patient Initial
Initial above to acknowledge receipt of "Patient Privacy Information" document.
I've authorized The Leaves to share my healthcare information with the following people, besides my Christian Science practitioner and agents for billing:
Name
Relationship
Name
Relationship
Name
Relationship
Acknowledgment of receipt of "Christian Science Nurse Scope of Services."

Please click here for "Christian Science Nurse Scope of Services" document.
Patient Initial
Initial above to acknowledge receipt of "Christian Science Nurse Scope of Services" document.
Acknowledgment of Policy Regarding Personal Property

We recommend that valuables are not brought to The Leaves. If necessary, small valuables such as credit cards, cash, or jewelry may be placed in the office safe. Your initials below signify that you understand The Leaves' policy regarding personal property.
Patient Initial
Please list below (if applicable) and mobility aids (such as a wheelchair or walker) and/or audio equipment (such a CD player or headphones, etc.) which you will bring:
Type in mobility aids or audio equipment you will bring
Request for Side Rails to Enhance Mobility

If you request the use of the side rails on my bed to assist with mobility (as an enabling device), then please initial here.
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
THE LEAVES
Uniting in Love to rise higher in Christian Science nursing.

The Leaves provides Christian Science nursing in an inspiring, gracious and healing atmosphere.
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APPLICATION AGREEMENT FOR STAYS AT THE LEAVES

THE LEAVES