Bradford Ecumenical Home Admission Application

Date*

MM

DD

YYYY

Personal Data

Last*

First*

Middle Initial

Maiden Name

Address*

Street Address City State ZIP Code

How long has he/she lived there?*

Birthdate*

MM

DD

YYYY

Age*

Birthplace*

Marital Status*

Religious Preference

Referred by:

Person(s) to be notified in case of emergency:

Name

First Last

Address

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

Relationship

Home Phone

Work Phone

Cell Phone

Email

Would you like to add a secondary emergency contact?

Yes
No

Name

First Last

Address

Street Address City State ZIP Code

Relation

Home Phone

Work Phone

Cell Phone

Email

Name of Attending Physician*

Check all that apply:

Anticipated length of stay:*

Short Term Rehab
Long Term Placement

Is applicant currently hospitalized?*

Yes
No

If yes, where?

FINANCIAL DATA

Social Security Number

Medicare Number

Does the resident handle his/her own finances?*

Yes
No

If not, who will be the responsible party?

Name

First Last

Relation

Address

Street Address City State ZIP Code

Home Phone

Work Phone

Untitled

First Choice
Second Choice
Third Choice

Legal Status

Power of Attorney
Conservator
Social Security Representative Payee

Does the resident pay medical insurance premiums?*

Yes
No

If yes, amount:

How often?

Can the resident afford to pay for long term nursing home care?*

Yes
No

If no, will the resident be applying for assistance for nursing home care?*

Yes
No

What county?*

Monthly Income

Enter the amount of income for each item based on a monthly amount.

Social Security

Private Pension

Veterans Benefits

RR Retirement

Dividends

Interest

SSI

Public Welfare

Other

TOTAL

Bank Accounts/CD's/Trust Accounts

Name of Bank

Bank Address

Account Number

Account Type

Account Balance

Account Balance as of:

Add another account?

Yes
No

Name of Bank

Bank Address

Account Number

Account Type

Account Balance

Account Balance as of:

Add 3rd Account?

Yes
No

Name of Bank

Bank Address

Account Number

Account Type

Account Balance

Account Balance as of:

Real Estate

Do you own any real estate?*

Yes
No

Property Address*

Street Address City State ZIP Code

List all owners of property:

Market Value*

Add another property?

Yes
No

Property 2 Address*

Street Address City State ZIP Code

List all owners of property 2:

Health Insurance

Name:

ID #

Group #

Name:

ID #

Group #

Long Term Care Policy

Name of Company

Policy #

Medicare Part D

Medicare Part D Plan

Yes
No

Name

Advance Directives

Mark all Advance Directives that are in place.

DNR
Living Wil
Health Care Proxy
Medical POA

Funeral Home Information

Funeral Home Name

Funeral Home Phone

Funeral Home Address

Street Address City State ZIP Code

Copies of the following are required at time of admission:

There is no need to send these items now. Do not check boxes.

To be filled out at time of admission:

Social Security Card
Medicare Card
Health Insurance Card
PACE Card
Proof of Birth Date
Power of Attorney
Living Will
DPW Access Card

By typing your full name you are signing this document and agree that all information is true to the best of your knowledge.

I am the:*

Applicant
Responsible Party

Type Your Full Name*

Application must be completed in full and signed to be processed. Bradford Ecumenical Home, Inc. does not discriminate on the basis of sex, race, color, religion, creed, age, national origin, ancestry, sexual orientation or disability.