Admission Form | Rochester Presbyterian Home: Memory Care Communities in Rochester, Chili, Fairport

Date of Application

Preferred Community

Application Demographics:

Name of Applicant:

Address

Street Address Address Line 2 City State ZIP Code

Telephone:

Current Location of Applicant: (please check)

Social Security Number:

Birth Date:

Sex:

Marital Status:

Religious Affiliation:

Church:

Life Time Occupation:

Veteran (self or spouse):

Branch:

Primary Care Physician’s Name:

Phone

Address

Street Address Address Line 2 City State ZIP Code

Local Hospital of choice, (If hospitalization is ever needed):

Other Physicians that the Applicant is known to:

(Example: Dentist, Cardiologist, Neurologist, Psychiatrist, Ophthalmologist, Orthopedist, etc…) ***Please provide a Physician Names, Addresses, Specialty and Telephone Numbers.

Applicant’s Insurance Information:

Medicare Number:

Other Health Insurance:

Policy Number:

Long Term Care Insurance:

Policy Number:

Prescription Coverage:

Applicant’s Representative for Health Care Decisions:

Check Yes if Rep same as Financial representative or complete below:

Yes
No

Name

Relationship:

Address

Street Address Address Line 2 City State ZIP Code

Home Telephone:

Work Phone:

Cell Phone:

Pager:

Healthy Care Proxy:

Yes
No

Living Will/Advance Directives in Place:

Yes
No

Memorial Arrangements in Place:

Yes
No

Arrangements planned with:

Anatomical Gift Program:

Yes
No

Copies of the following documentation will be requested

Medicare Card
Insurance Cards (Health Insurance, Prescription Insurance &/or Long term care insurance)
Power of Attorney
Health Care Proxy &/or any Advance Directives, (MOLST, Living Will, etc…)
Social Security Card
Anatomical Gift Donor Card (If indicated)

Please bring applicable items to the Pre-Admission appointment for copies to be made or feel free to attach copies to our application.

The Rochester Presbyterian Home is a not for profit Adult Home. We respect the rights of all people and applications are considered without regard to race, creed, color, age, gender, marital status, disability, sexual orientation, national origin or sponsor.

Applicant’s Representative for Financial Decisions:

Name

First Last

Relationship:

Address

Street Address Address Line 2 City State ZIP Code

Home Telephone:

Work Phone:

Cell Phone:

Email:

Bank Power of Attorney:

Yes
No

Durable Power of Attorney:

Yes
No

Conservatorship/Guardian:

Yes
No

Does the Applicant have a trust?

Yes
No

Has there been a transfer of funds/assets/real estate in the past 36 months?

Yes
No

Applicant’s Financial Information:

Monthly Income:

Salary:

Social Security:

Pension:

Other Income:

Total Monthly Income:

Assets:

Owns Real Estate:

Life Insurance (cash value):

Savings:

Investments:

Other Assets Estimated Value:

Total Value of Assets:

Liabilities:

Home Mortgage:

Loan/Installment Payments:

Other Liabilities:

Additional Financial Information:

Signature

Contacts In Case of Emergency

Please list, in order of preference, the four family members/friends whom you would like us to contact in the event of an emergency:

#1 Name

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email

#2 Name

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email

#3 Name

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email

#4 Name

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email