Admission

Application for Admission

Anticipated Admission

As Soon As Possible       (Other) Specify

General Information Concerning Prospective Resident

Name

Address

City     State      Zip Code

Phone

Resident is now at _______________ Home Hospital Nursing Home

Identify Institution (if applicable)

Institution Name

Address

City    State     Zip Code

Phone

How Long      Adm. Date

Birthdate    Age    Sex _______ Male Female

Social Security No.

Marital Status ______________ Married Widowed Divorced Separated Single     Name of Spouse

Spouse's Address

City     State     Zip Code

Who has written Power of Attorney?

Name    Relationship

Address

City    State    Zip Code

Home Phone    Work Phone

Occupation

Next of Kin #1

Name    Relationship

Address

City    State    Zip Code

Home Phone    Work Phone

Next of Kin #2

Name    Relationship

Address

City    State    Zip Code

Home Phone    Work Phone

Next of Kin #3

Name    Relationship

Address

City    State    Zip Code

Home Phone    Work Phone

What is the resident's Medicare Number?

Does he/she have:  Part A    Part B

Is this Railroad Retirement?  Yes  No

Does resident have 65 extended?  Yes No   Blue Cross #

Does resident have any other insurance that will cover Nursing Home?  Yes No

If yes, please identify:  Company

Policy Number

Agent's Name

Billing Address

Other Health Insurance (give name & address of company, policy # and beneficiary)

Does resident have personal physician?  Yes    No

If yes, please identify:  Physician's Name

Address

Phone

Will physician attend here?  Yes  No

Opthamologist

Podiatrist

Dentist

Religion

Church & Pastor

Medical Information Concerning Prospective Resident

Previous Admission to Other Facilities including Mental Hospitals, Nursing Homes or Personal Care Homes

Name of Facility #1

Date of Stay

Reason for Admission

Name of Facility #2

Date of Stay

Reason for Admission

Name of Facility #3

Date of Stay

Reason for Admission

Has the resident ever been certified for skilled nursing care?  Yes    No

Height    Weight

Allergies:

Medication

Food

Other

Cognitive Status:

Alert: Yes   No            Noisy: Yes   No

Wanders: Yes   No         Forgetful: Yes   No

Combative: Yes   No        Confused: Yes   No

Financial Information Concerning Resident

Will the resident pay for stay out of own funds?  Yes   No

Expected length of stay: 

Short Term (3 Months or less)

Long Term (Over 3 Months)

Complete financial information if long term stay is anticipated.

Cash Assets

Monthly Income

Source

Bank    Location

Checking Account #     Approx. Account Balance

Savings Account #    Approx. Account Balance

Certificate of Deposit?  Yes    No

If yes, approximate amount

Other Assets Specify

Approx. Total Assets of Resident

If it is necessary for a short term stay to become long term, financial information will be necessary and may assist in determining the resident's eligibility for financial assistance.

CLICK to download the Authorization Form.

To complete your admission, (1) print, (2) sign and (3) mail the authorization form to:

Mountain View Care Center
2309 Stafford Avenue
Scranton, PA 18505

 

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Mountain View Care Center