Application for Admission

Application for Admission
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Name of Person Completing Application:

First NameLast Name
Relationship to Applicant:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Fax:
Applicant has (check all that apply):

Other
*Official documentation of legal representative must be provided prior to admission *
Name:

First NameLast Name
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Person(s) financially responsible for applicants' care:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Reason applicant is seeking residential treatment or long-term care (include diagnosis, current living situation, goals of treatment, etc.):

Name of Current Optometrist:

First NameLast Name
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:

First NameLast Name
Phone:
Format: (000) 000-0000.
Relationship to Applicant:
Phone:
Format: (000) 000-0000.
Other important relationships/contacts (i.e. therapist, case manager, family members, friends, etc.):
Name(s):

First NameLast Name
Relation to Applicant:
Phone:
Format: (000) 000-0000.
Name(s):

First NameLast Name
Relation to Applicant:
Phone:
Format: (000) 000-0000.
*Averte requires a signed release of information for any organization or individual with whom the applicant would like us to communicate regarding their application and/or care.
Insurance Information
Private Insurance Provider:
Primary Insured:

First NameLast Name
ID#:
Group#
Medicare Parts A+B #:
Date Effective:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Part D Plan Name:
ID#:
Rx BIN#
Date Effective:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
VT Medicaid ID# (if applicable):

Is there a person or an organization we can thank for this referral?
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Please check either or both boxes if you do not wish to receive these communications:
Please check either or both boxes if you do not wish to receive these communications:
Choosing not to receive these communications will not affect access to services, treatment, payment, or eligibility for benefits. You may change your preferences at any time by contacting Maggie.Beaman@triviumlifeservices.org or by using the unsubscribe link included in our emails.

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Fax: (855) 887-7114 2122 Lower Plain Bradford VT 05033 Ph:(802) 222-8028
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