Levindale > Application for Admission

Application for Admission

In order to complete the application, a copy of the following documents must be provided:

  • Medicare Card
  • Living Will/Advanced Directive
  • Medicaid Card
  • Social Security Card
  • Private Insurance Card
  • Power of Attorney – Medical and Finance

* Indicates required information

Name of Resident: *



Date: *



Home Address: *



Gender: *





Age: *



Marital Status: *







U.S. Citizen: *





Current Placement: *








Hospitalization within 30 days: *





If yes, what was the date of hospital admission:


Name of Spouse/Responsible Party: *



Home Address of Spouse/Responsible Party: *



Spouse/Responsible Party Telephone Numbers:

Home: *



Work: *



Mobile: *



Spouse/Responsible Party Email: *



Medical Information

Primary Care Physician: *



Address: *



Telephone Number: *



Current Health Issues: *



Any Other Health or Long Term Care Insurance?: *
If yes, please provide copy of the insurance card.





Allergies to animals?: *





If yes, please specify


Hiring a companion or sitter?: *





If resident is unable to make financial/medical decisions, who is responsible?

Name:


Relationship to Resident:


Address:


Telephone Number:


Email Address:


Advanced Directives: *





Additional Relatives/Significant Others:

Name:


Relationship to Resident:


Address:


Telephone Number:


Email Address:


Financial Information

The following information is required concerning the Resident’s finances. Please indicate the resources which are available to pay for the cost of the care. The information supplied will be strictly confidential and will be used to assist you in your long-term planning.

Has anyone been appointed Power of Attorney/Guardian?: *





If yes, who?


Is the Resident planning to apply for Maryland Medical Assistance?: *





If the resident has applied what was the date of the application?:


In what county?:


Have any of the Resident’s assets been transferred in the last 5 years?:




If yes, amount?


PAYMENT TERMS

It is the policy of Levindale Hebrew Geriatric Center and Hospital to collect the equivalent to one month’s room charge in advance and at the beginning of each subsequent month. Resident bills owed monthly and the amount due is payable upon receipt. Amounts unpaid by the end of the month will be subject to late charge as provided in the Admissions Agreement.

PLEASE SIGN BELOW

I hereby affirm that, to the best of my knowledge, the financial information provided is accurate and complete and the assets listed are available to pay for the Resident’s care at Levindale Hebrew Geriatric Center and Hospital. The nursing center has my permission to obtain a credit report of the application or contact the financial institutions listed herein.

Signature of Health Care Agent: *

Date: *



Signature of Health Care Agent:
Date:


 
Authentication: *

CAPTCHA