APPLICATION FOR RESIDENCE

CONFIDENTIAL

DATE_____________________________

FIRST NAME: ________________________ MIDDLE INITIAL: ____ LAST NAME:______________________  SEX:_______ RELIGION:_____________________________   DESIRED DATE OF RESIDENCE:________________________________

SOCIAL SECURITY: _____________________________         BIRTHDATE: _____________________________________

MARTIAL STATUS: _________________ HEIGHT: ______ WEIGHT: _____________ EYE COLOR: _____________

HAIR COLOR: _________________

RACE/ETHNICITY:     BLACK   HISPANIC   WHITE   PACIFIC ISLANDER/ASIAN    AMERICAN INDIAN

                                      ALASKAN   OTHER ____________________      (CIRCLE ONE)

TERM CHOICE:  LONG TERM        SHORT TERM    (CIRCLE ONE)

BILLING, POWER OF ATTORNEY AND DESIGNATED PARTY INFORMATION

DESIGNATIONS ARE:       PA – POWER OF ATTORNEY, BP – BILLING PARTY, LG – LEGAL GUARDIAN,

DP – DESIGNATED PARTY (Emergency Contact Party)

NAME: _____________________________________________________________________________

DESIGNATIONS: _____________________ USE CODES: PA, DP, BP

RELATIONSHIP: ______________________________________________________________________________________

ADDRESS____________________________________________________________________________________________

CITY: _____________________________ STATE: __________________________ ZIPCODE: ________________________

HOME PHONE: (       ) _______________________________ WORK PHONE: (      )_____________________________

EMAIL ADDRESS: ______________________________________________________________________________________

NAME:_____________________________________________________________________________

DESIGNATIONS: _____________________ USE CODES: PA, DP, BP

RELATIONSHIP: _______________________________________________________________________________________

ADDRESS: ____________________________________________________________________________________________

CITY: ______________________________ STATE: ____________________________ ZIPCODE: _____________________

HOME PHONE _(___)_______________________________ WORK PHONE_(___)_____________________________

EMAIL ADDRESS:______________________________________________________________________________________

RESIDENT NAME: ___________________________________________________________________________________________

RESIDENT MEDICAL INFORMATION

MEDICARE NO: _____________________________________ MEDICAID NO: ___________________________________________

INSURANCE COMPANY: ______________________________________________________________________________________

POLICY NUMBER: ___________________________________________________________________________________________

GROUP NUMBER: ___________________________________________________________________________________________

PLAN NUMBER: _____________________________________________________________________________________________

HOSPITAL PREFERENCE: ____________________________________________________________________________________

AMBULANCE SERVICE: _____________________________________________ PHONE: __________________________________

FUNERAL HOME: __________________________________________________ PHONE: __________________________________

RESIDENT DRUG PAYMENT PLANS:         YES        NO

PLAN NAME                                                         PLAN NUMBER                                                                   EXPIRATION DATE

___________________________                 _______________________________                        ___________________________

__________________________                   ________________________________                     ____________________________

OTHER MEDICAL INFORMATION:

FLU SHOT:                          YES        NO                                          DATE RECEIVED: _________________________________________

PNUEMONIA SHOT:          YES        NO                                          DATE RECEIVED: _________________________________________

TETANUS SHOT:               YES        NO                                          DATE RECEIVED: _________________________________________

DME:                                      YES        NO                                          DATE RECEIVED: _________________________________________

DENTURES:                        YES        NO                                          IF YES:                  FULL                      UPPPER               LOWER

                                                                                                                                                PARTIAL               UPPER                  LOWER

GLASSES:                            YES        NO                                          DESCRIPTION: ____________________________________________

HEARING AIDES:               YES        NO                                          DESCRIPTION: ____________________________________________

CONTINENT OF BOWEL:                               YES        NO                          CONTINENT OF BLADDER:                           YES        NO

ALLERGIES MEDICATION:              YES        NO          FOOD:                   YES        NO          INSECT BITES:                   YES        NO

IF YES, DESCRIBE: __________________________________________________________________________________________

UNUSAL MARKS/TATOOS/SCARS: _____________________________________________________________________________

___________________________________________________________________________________________________________

DIET: ______________________________________________________________________________________________________

DOES THE RESIDENT USE:           CRUTHCES         CAN       WALKER               WHEELCHAIR     PROSTHESIS

DESCRIPITION: _____________________________________________________________________________________________

RESIDENT NAME: ___________________________________________________________________________________________

MEDICAL HISTORY: __________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

RESIDENT DOCTORS:

FAMILY DOCTOR: ___________________________________________________________________________________________

ADDRESS: _________________________________________________________________________________________________

CITY: ________________________________________ STATE: __________________ZIPCODE: ____________________________

TELEPHONE: (         ) _________________________________________________________________________________________

PODIATRIST: __________________________________________________ USE IN HOUSE REFERRAL:                          YES        NO

ADDRESS: _________________________________________________________________________________________________

CITY: ________________________________________ STATE: __________________ZIPCODE: ____________________________

TELEPHONE: (         ) _________________________________________________________________________________________

OPHTHALMOLOGIST: ________________________________________________________________________________________

ADDRESS: _________________________________________________________________________________________________

CITY: ________________________________________ STATE: __________________ZIPCODE: ____________________________

TELEPHONE: (         ) _________________________________________________________________________________________

DENTIST: __________________________________________________________________________________________________

ADDRESS: _________________________________________________________________________________________________

CITY: ________________________________________ STATE: __________________ZIPCODE: ____________________________

TELEPHONE: (         ) _________________________________________________________________________________________

HOSPITALIZATIONS WITHIN THE LAST YEAR:

DATE ADMITTED               HOSPITAL                                            REASON FOR ADMISSION                             DISCHARGE DATE

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

RESIDENT NAME: ___________________________________________________________________________________________

RESIDENT PERSONAL INFORMATION:

NICKNAME: _________________________________________________________________________________________________

BIRTHPLACE: _______________________________________________________________________________________________

AREA CURRENTLY FROM: ____________________________________________________________________________________

OCCUPATION: ______________________________________________________________________________________________

SPECIAL DATES: ____________________________________________________________________________________________

INTERESTS/HOBBIES: ________________________________________________________________________________________

FAMILY MEMBERS:

_______________________________ RELATION: ______________________________ PHONE: ____________________________

_______________________________ RELATION: ______________________________ PHONE: ____________________________

_______________________________ RELATION: ______________________________ PHONE: ____________________________

FRIENDS:

_______________________________ RELATION: ______________________________ PHONE: ____________________________

_______________________________ RELATION: ______________________________ PHONE: ____________________________

DOES THE RESIDENT DRIVE A CAR: ____________

INSURANCE CARRIER: ______________________________________________________

PERSONAL ITEMS SUCH AS SHAMPOO, TISSUE, DEODORANT, SOAP, POWDER, DENTURE CREAM, TOOTHPASTE, TOOTHBRUSH, COMBS, BRUSHES, MAKE-UP, PERFUME, ETC. IS THE RESPONSIBITY OF THE RESIDENT.  PLEASE CHECK WITH PROCEDURE YOU PREFER.

_________ RESPONSIBILITY OF FAMILY TO PROVIDE

_________ RESPONSIBILITY OF FACILITY TO PURCHASE AND CHARGE RESIDENT IN MONTHLY INVOICE

_________ RESPONSIBILITY OF RESIDENT TO PURCHASE ON RESIDENT SHOPPING TRIPS

RENT IS DUE BY THE 7ST DAY THE MONTH, INVOICES WILL BE MAILED

I, ____________________________________________ CERTIFY THE ABOVE INFORMATION IS CORRECT.

            (Print name of person filling out form)

______________________________________________ SIGNATURE OF PERSON FILLING OUT FORM.