Admission - Bradford

Apply for admission online safely and securely.

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*
Month
Day
Year
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:
MM slash DD slash YYYY
Date of Birth:
MM slash DD slash YYYY
If Spouse is deceased, Date of Death:
MM slash DD slash YYYY
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
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
MM slash DD slash YYYY

Read our Open Admissions Policy

PERSONAL INFORMATION

MARITAL STATUS

VETERAN INFORMATION:

DESIGNATED PERSON (S)

TRAVEL HISTORY

MEDICAL HISTORY AND HEALTH STATUS

Immunization History

MONTHLY INCOME

BANK ACCOUNTS/INVESTMENTS/REAL ESTATE

INSURANCE COVERAGE

LEGAL DOCUMENTS

MISCELLANEOUS