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Long Term Care and/or Rehabilitation Pre-admission Information
I. General Information
Date:
Patient's Name:
Last:
First:
Address:
City:
State/Zip:
Patient's Present Location (if different than home address)
Address:
City:
State/Zip:
Person Representing Patient:
Address:
City:
State/Zip:
Phone No.:
Email Address:
Status (please check appropriate response)
Patient's Marital Status:
Medicaid Application Pending:
Primary Physician:
US Citizen:
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 #
Savings Account(s)
1. Bank
Name on Account:
Acct #
2. Bank
Name on Account:
Acct #
Certificates of Deposit:
Bank/Financial Institution:
Does the Resident Own a Home?
Is the home joined jointly with anyone?
Other Assets: (Please list)
Amount
1.
$
2.
$
3.
$
4.
$
Have any assets been transferred within the last 5 years?
If yes, please describe:
Has an Estate Trust been established?
Hospital Preference:
Veteran
________________________________________________________
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.
