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Long Term Care and/or Rehabilitation
Pre-admission Information
   
I. General Information  
Date:  
Patient's Name:  
Last: First:    Initial:
Address:
City: State/Zip:
Patient's Present Location (if different than home address)
Address:
City: State/Zip:
Person Representing Patient:   Relationship:
Address:
City: State/Zip:
Phone No.: Email Address:
Status (please check appropriate response)
Power of Attorney Conservator
Person Responsible for handling financial transactions
Patient's Marital Status: Single Married Widowed Separated Divorced
Medicaid Application Pending: Yes No    If yes, date submitted
Primary Physician:  
US Citizen: Yes No  
   
II. Financial Disclosure (Information is considered confidential)
   Income    Monthly Amount
Social Security $
Retirement Pension $
Veteran's Pension $
Railroad Pension $
Supplementary Security Income $
Annuities $
Other Income $
Total Monthly Income $
   
Assets:  
Checking Account  
Bank: Name on Account:
Acct #   Balance $  Joint Account Yes No
Savings Account(s)  
1. Bank Name on Account:
Acct #   Balance $   Joint Account Yes No
2. Bank Name on Account:
Acct #   Balance $   Joint Account Yes No
Certificates of Deposit:
Bank/Financial Institution:
Does the Resident Own a Home?    Yes No Estimated Value $
Is the home joined jointly with anyone? Yes No
   
Other Assets: (Please list) Amount
1. $
2. $
3. $
4. $
Have any assets been transferred within the last 5 years? Yes No
If yes, please describe:
Has an Estate Trust been established? Yes No
Hospital Preference:
Veteran Yes No     Spouse of Veteran Yes No
To the best of my knowledge, all of the information herein is correct and valid.
________________________________________________________
Signature of Resident or Responsible Party Date

The information provided shall remain confidential and shall be made available only to authorized personnel involved in the placement process and to government officials authorized by law to such records.

The facilities having access to this information do so without regard to race, creed, color, age, sex, religion, national origin, sponsor, sexual preference, marital status; persons under 16 years of age are not eligible for admission consideration unless special approval has been received from the Department of Health.