Pre-Admission Application Form - Eastwood Nursing Center

Name of Applicant*
First Middle Last
Who is making this referral?
Name*
First Last
Home Phone*
Work Phone
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to Applicant*
Admission and Business Matters
If this person is accepted for admission, who will be the person responsible for handling admission and business matters?*
- Same as Above
- Other
Name*
First Last
Home Phone*
Work Phone
Address*
Street Address Address Line 2 City State ZIP Code
Relationship to Applicant*

Financial & Legal
What is the anticipated source of payment?*
Medicare Number
Medicaid Number
Is the applicant capable of handling his/her own affairs?*
- Yes
- No
Explain
List all current health insurance and include all numbers.
Name of Company Address Policy Holder Numbers
Photo Copies of all Insurance Cards
Drop files here or

Accepted file types: jpg, png, jpeg, pdf.
Has applicant applied for, but not been notified of status of Medicaid application?*
- Yes
- No
Where was it filed?
County?
If known, please indicate name of Social Services worker
Does this person have a Legal Guardian or Power of Attorney?*
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Phone (Personal)
Phone (Work)

Social Services & Activities
Please list the names and phone numbers of applicant's close family members or friends.
Name Phone Number
What is the applicant's former occupation?*
List any important life events of this person (both good & bad).
List any hobbies or activities he/she might enjoy?
These may include anything from visiting with others to reading or watching TV.
List anything specific you think would be important for us to know.
This can include "likes" and "dislikes."
Do you see this placement as permanent or temporary?
- Yes
- No
Please Explain*
Does this person accept the idea of nursing home placement?*
- Yes
- No

Financial Information
Anticipated Date of Admission*
Amount of:
Social Security
Please enter a number greater than or equal to 0.
Veteran's Pension
Please enter a number greater than or equal to 0.
Pension
Please enter a number greater than or equal to 0.
Other Income
Please enter a number greater than or equal to 0.
Accounts and Balances/Values
Savings
Please enter a number greater than or equal to 0.
Checking
Please enter a number greater than or equal to 0.
Stocks
Please enter a number greater than or equal to 0.
Bonds
Please enter a number greater than or equal to 0.
Certificates of Deposit
Please enter a number greater than or equal to 0.
Insurance Policies
Name of Company
Cash Value
Please enter a number greater than or equal to 0.
Other
Property deeded in applicant's name
Estimated Value of Property
Please enter a number greater than or equal to 0.
Burial Trust
- Yes
- No
- Revocable
- Non-Revocable
Do you anticipate applying for medicaid?*
- Yes
- No
When
Pay source and/or financial arrangements will be discussed with the social worker prior to admission. Copies of insurance cards, Medicaid/Medicare cards, and Social Security cards must be available prior to admission.

I will inform the facility of the date and time of the appointment for application. I understand that failure to complete a Medicaid application or denial from Medicaid shall make the applicant financially responsible.
*
- To the best of my knowledge, the above information is complete and accurate.

In order for us to process your admission, we require certain financial information. Please take a moment to read the following information regarding pay source information and answer the questions.

Medicare Coverage in a Skilled Nursing Facility (SNF)
- Medicare covers certain skilled care services that are needed daily on a short-term basis (up to a potential 100 days) A Co-Pay, which changes each January 1 will be charged by Medicare after day 20.
- Medicare will cover skilled care if you have qualifying hospital stay of 3 or more consecutive days, not including the day you leave the hospital.
- You must enter the SNF within 30 days of discharge from the hospital.
- Skilled care is health care given when you require skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.
- Examples of skilled care include changing sterile dressings and physical therapy.
- Your doctor must decide whether you require skilled care.
- You must be able to participate and tolerate skilled care.
After Medicare coverage has ended, there are two ways to apy for nursing home care; Self-pay or Medicaid. Please check one to indicate your anticipated source of payment.

Medicaid is a state and federal program which provides assistance with medical expenses for persons who are financially indigent. You must meet medical and financial requirements to qualify. If your personal assets are $2,000.00 or less you may be eligible for Medicaid.

Self-Pay* is to personally pay the daily room rate plus additional charges for supplies and pharmacy.

* If self-pay, how long do you anticipate paying privately?
Anticipated Source of Payment
- Medicaid
- Self Pay
- Financial plans are uncertain. We intend to contact an attorney.
How long do you anticipate paying privately?
- 1 - 6 Months
- 6 - 12 Months
- Longer
Name of Prospective Admission
First Last
Name of Responsible Party
First Last

Pre Admission Application

Pre-Admission Form

Who is making this referral?

Admission and Business Matters

General Information Relating to Applicant

Financial & Legal

Medical & Nursing Information

Social Services & Activities

Financial Information

Amount of:

Accounts and Balances/Values

Insurance Policies

Other

Other Information

Name of Company	Address	Policy Holder	Numbers

Name	Phone Number