Admission Form

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  • Date Format: MM slash DD slash YYYY
  • Application Demographics:

  • Date Format: MM slash DD slash YYYY
  • (Example: Dentist, Cardiologist, Neurologist, Psychiatrist, Ophthalmologist, Orthopedist, etc…) ***Please provide a Physician Names, Addresses, Specialty and Telephone Numbers.
  • Applicant’s Insurance Information:

  • Applicant’s Representative for Health Care Decisions:

  • 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:

  • Applicant’s Financial Information:

  • 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: