Admission | Bradford

Interested In:

PERSONAL INFORMATION

Full Name:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Birth Date*

MM

DD

YYYY

Birth Place:

Maiden Name:

Social Security Number

Referred by:

Desired Date of Occupancy:

Current Living Arrangements

Living Alone
Live With Children
Rent
Own
Other

If Other, please explain

MARITAL STATUS

Check One

Married
Single
Separated
Divorced
Widow

Spouse's Full Name:

Date of Marriage:

Date of Birth:

If Spouse is deceased, Date of Death:

VETERAN INFORMATION:

Are you a Veteran?

Yes
No

Is your spouse a Veteran?

Yes
No

If yes, list branch:

Dates of service

Served during active wartime?

Yes
No

If yes, which war?

DESIGNATED PERSON (S)

Notifications will be made in the order names are listed

Name:

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email

Name:

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email

Name:

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email

TRAVEL HISTORY

Have you traveled outside the United States within the past year?*

Yes
No

If Yes, where and what dates?

Have you received any medical care outside the United States to include an overnight stay, surgery, or procedure within the past year?

Yes
No

If yes, name and location of healthcare facility

Dates of admission of surgery/procedure

Type of care received (surgery or procedure)/reason for admission

Have you received extended medical care in a healthcare facility outside of Pennsylvania, particularly stays in a long term acute care or skilled nursing facility within the past 6 months?

Yes
No

If yes, name and location of healthcare facility:

Reason for admission:

Date(s) of admission:

MEDICAL HISTORY AND HEALTH STATUS

Surgery and Dates

Accidents

Mental Health Treatment

Yes
No

If so, when?

Where?

Physician

Allergies (Food, Medicine, Otherwise)

Immunization History

Current Flu Vaccine:*

Yes
No

If yes, when and where?

Pneumovax:*

Yes
No

If yes, when and where?

Have you ever been diagnosed with Covid-19?*

Yes
No

If yes, when & where?

Have you received a Covid-19 vaccine?*

Yes
No

If yes, list Vaccine Dates, Vaccine Brand and where you received your vaccination.

Prosthetic Devices

Cane
Walker
Manual wheel chair
Motorized wheel chair
Hearing aid(s)
Dentures
Eye glasses
Pacemaker
Other

Do you require a special diet?

Yes
No

Please explain

Do you require assistance with a tub or shower?

Yes
No

Please explain

Do you require assistance with personal grooming?

Yes
No

Please explain

Do you require assistance with dressing?

Yes
No

Do you have difficulty controlling your bowel?

Yes
No

Do you have difficulty controlling your bladder?

Yes
No

Do you smoke?

Yes
No

How often?

Do you drink alcohol?

Daily
Occasionally
Never

Please list current medications and/or medical treatments that you require.

Physician

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dentist

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Podiatrist

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Optician

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Current Pharmacy

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Hospital Preference

Most recent hospitalization (hospital, date, reason)

MONTHLY INCOME

Social Security

SSI

Veterans Benefits (specify program(s))

Interest/Dividends

Pension

Other Income

BANK ACCOUNTS/INVESTMENTS/REAL ESTATE

Name of Bank

Bank Address

Account Number

Account Type

Account Balance

Add Another Account?

Yes
No

Bank Name

Bank Address

Account Number

Account Type

Account Balance

Add 3rd Account?

Yes
No

Bank Name

Bank Address

Account Number

Account Type

Account Balance

Do You Have Any Stocks, Bonds, CD's and/or IRA?

Yes
No

Name and Market Value

Do you own real estate?

Yes
No

Location

Value

Do you own any other real estate?

Yes
No

Location

Value

In the past 60 months have you or your spouse closed, given away, sold or transferred any assets such as: a home, land, personal property, life insurance policy, annuities, bank accounts, CD's, stocks, bonds, IRA's, or right to any income?

Yes
No

What was transferred and the amount?

In the past 60 months have you or your spouse transferred any assets into a trust?

Yes
No

What was transferred and the amount?

INSURANCE COVERAGE

Medicare Number

PA Medicaid Number

Supplemental Insurance (Name & ID#, Group Number, Monthly Premium)

Long Term Care Insurance

Does it have a Personal Care Home Rider?

Yes
No

Other Health Insurance

Group Number

Medicare Part D Prescription Drug Coverage?

Yes
No

PACE Membership Number

LEGAL DOCUMENTS

Do you have a Financial Power of Attorney?

Yes
No

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Do you have a Social Security Representative Payee?

Yes
No

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Do you have a Living Will?

Yes
No

Do Not Resuscitate?

Yes
No

Do you have a POLST?

Yes
No

Do you have a Medical Power of Attorney?

Yes
No

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Do you have an irrevocable burial fund?

Yes
No

Amount?

Name of Funeral Home

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

MISCELLANEOUS

Religion

Church

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pastor

Phone

School: Highest grade or degree completed

Location

Work History (Occupation(s) and Employment)

Do you drive?

Yes
No

Do you have your own vehicle?

Yes
No

Do you plan to bring your vehicle?

Yes
No

Make and Model

Year

Color

License Plate

Admission Policy*

I have read the Admission Policy

It is the policy of Bradford Ecumenical Home, Inc. to admit and treat all residents without regard to race, color, national origin, ancestry, age, sex, religious creed, disability or handicap. As such, no resident shall be excluded from participation in, be denied benefits of, or otherwise be subject to discrimination in the provision of any care or service on the grounds of race, color, national origin, ancestry, age, sex, religious creed, disability or handicap.

I certify that I have read the admission policy or have had it read and explained to me and apply for admission, answering questions to the best of my knowledge, with the understanding that these conditions will apply to me as a resident of Bradford Ecumenical Home, Inc.

Name of individual completing this application

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date