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Steuben County Health Care Facility
Admission Application
Applicant
Name__________________________________________________________________________
First Name
Middle
Last Name
(maiden name)
Where is the applicant
presently?______________________________________________________________
Home address _______________________________County of
Residence________________________
Phone Number (___) _____-_____ Sex _________ Marital Status ____________Veteran
Y___ N ____
Date of Birth ______________________________ Place of Birth
_____________________________________
Spouse's Name ____________________________Social Security Number
__________-__________-________
Physician _________________________________ Religion
_________________________________________
Previous Nursing Home stay? Y___ N___ Where __________________________When
______________
Where __________________________When ______________
Where
__________________________When ______________
Advanced Directives: Proxy Y ____ N
____ DNR Y ____ N ____
Living Will Y ____ N ____
(A copy will be requested at the time of Admission)
Previous Occupation ____________________________ Date of Retirement
Month_________ Year __________
Applicant / Spouse a Veteran Y_____ No _____
Funeral Home ________________________________ Phone Number (____) _______ -
_______
Pre-paid Funeral Arrangements Y ____ N ____
PERSON TO NOTIFY IN TIME OF EMERGENCY
Name_______________________________________ Relationship
______________________________________
Address
______________________________________________________________________________________
# Street
Apt. #
City
State
Zip
Home Phone (____) _____ - ______ Work Phone (____) ______ -
_______
FAMILY MEMBERS / SIGNIFICANT OTHERS
Name _______________________________________ Relationship
____________________________________
Address
___________________________________________________________________________________
# Street
Apt. #
City
State
Zip
Home Phone (____) ______ - _______ Work Phone (____) ______ - ________
Name ____________________________________Relationship
_________________________________________
Address
_____________________________________________________________________________________
# Street
Apt. #
City
State
Zip
Home Phone (____) ______ - ________ Work Phone (____) _____ - _________
FINANCIAL INFORMATION
Medicare # _________________Medicare Part B Y___ N____ Medicaid
#______________County_____________
Other Insurance: Blue Cross/Blue Shield # _____________________ Phone # (____)
______ - ________
Other Health Insurance ___________________________________ Phone # (____)
______ - ________
Bank Accounts
Bank #1_____________________________Checking Balance $ ______________Savings
Balance $_____________
Bank #2_____________________________Checking Balance $ ______________Savings
Balance $ _____________
Bank #3_____________________________Checking Balance $ ______________Savings
Balance $ _____________
Assets: (1) Investments/location
_________________________________________Value $ ____________________
(2) Has applicant ever owned property Y _______ N ________
** if YES please complete the following:
Address of Current of Last owned Property:
Primary Residence _________________________________________________
Value $ ___________________________________
Is the above property still owned by applicant? Y _____ N _______
if YES - is there any outstanding mortgage/judgements? Y____
N_____
if NO - give approximate date of sale/transfer
______________________
Value at time of sale/transfer $_______________
(3) Other Assets: ie., trusts, CD's, car
___________________________________________
Information for trust - contact person, address, phone #
_______________________________________________________________________
Life Insurance Y____ N ____ With Whom?_______________Cash Value $
_______________
Income: (1) Social Security Amount
__________________________________________________
(2) Pension Amount _____________ Address/Phone # ____________________________
(3) Veteran's Benefits Amount _______________________________________________
(4) Rental Income ________________________________________________________
(5) SSI ________________________________________________________________
(6) Mortgage Income ______________________________________________________
(7) Interest Income ________________________________________________________
Person Managing Applicant's Funds
Name____________________________________________Relationship___________________________________
Address
______________________________________________________________________________________
# Street
Apt. #
City
State
Zip
Home Phone (_____) ______ - ________ Work Phone (____) _____ - _____
Power Attorney Y____ N ____ Name &
Address_____________________________________________________
Home Phone (____) _____ - _____ Work Phone (____) _____ - _____
Executor of Estate Y___ N ___ Name & Address
_____________________________________________________
Home Phone (____) _____ - ______ Work Phone (____) _____ - _____
** IN ORDER TO PROCESS YOUR APPLICATION IF A TIMELY MANNER
PLEASE COMPLETE THIS APPLICATION IN ITS ENTIRETY.
DO NOT LEAVE BLANKS. IF A QUESTION DOES NOT PERTAIN TO THE APPLICANT PLEASE
INDICATE SO BY n/a (not applicable).
According to the best of my knowledge and belief, the above information is
accurate and true in all respects.
_________________ ____________________________________________________________________
Date
Signature of Applicant
_________________
____________________________________________________________________
Date
Signature of Applicant
THE STEUBEN COUNTY HEALTH CARE FACILITY AND ALL OF ITS PROGRAMS,
SERVICES AND DIVISIONS, DO NOT DISCRIMINATE IN THEIR EMPLOYMENT, ADMISSION,
RETENTION OR DISCHARGE PRACTICES BASED ON RACE, CREED, COLOR, NATIONAL ORIGIN,
SEX, DISABILITY, MARITAL STATUS, AGE, SOURCE OF PAYMENT, OR SEXUAL ORIENTATION.
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