Admissions Application

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Applicant Demographics

First Name*

Last Name*

Middle Initial*

Nickname

Home Address*

City*

Zip Code*

Country*

Date of Birth

Gender

Male Female

Race

Home Phone

Work Phone

Cell Phone

Marital Status

Single Married Widowed Divorced Separated

U.S. Citizen

Yes No

Name of Church or Synagogue

Previous hospital stay

Primary Language

Current location of applicant

Are either you or your spouse a United States Veteran?

Yes No

Has the applicant had a previous nursing home stay in the past year?

Yes No

Insurance Coverage

Medicare #

Blue Cross #

Blue Choice #

Preferred Care #

Medicaid #

Medicaid County

Other Insurance #

Long Term Care Insurance?

Yes No

Additional Insurance Information

Primary Contacts (this is our contact order)

Please note the first two contacts may recieve media from St. John's Home.

Contact #1

First Name

Last Name

Relationship

Address

City

State

Zip

Home Phone

Cell Phone

Business Phone

Does the applicant have a Health Care Proxy?

Yes No

If yes, please provide copies at the time of admission.

Have Advance Directives been established (Living Will, DNR)?

Yes No

If yes, please provide copies at the time of admission.

Contact #2

First Name

Last Name

Relationship

Address

City

State

Zip

Home Phone

Cell Phone

Business Phone

Does the applicant have a Health Care Proxy?

Yes No

If yes, please provide copies at the time of admission.

Have Advance Directives been established (Living Will, DNR)?

Yes No

If yes, please provide copies at the time of admission.

Contact #3

First Name

Last Name

Relationship

Address

City

State

Zip

Home Phone

Cell Phone

Business Phone

Does the applicant have a Health Care Proxy?

Yes No

If yes, please provide copies at the time of admission.

Have Advance Directives been established (Living Will, DNR)?

Yes No

If yes, please provide copies at the time of admission.

Additional Contact Information

Do you have any family members employed at St. John's

Yes No

If so, what is their name?

Do you have a funeral home preference**

Yes No

Name of funeral home**

Funeral Home Phone*

Have you donated your body**

Yes No

If yes, where?**

Have you donated your eyes?**

Yes No

If yes, where?**

Who has the original cards?**

**This information must be on file, according to regulations, with at least a preference, if arrangements have not been made.
Copies of all cards must be provided upon admission. Cards may include:

Insurance Cards (including medicare part D cards)
Pharmacy Cards
Photo/Picture ID ***Identification is needed***
Health Care Proxy
Power of Attorney
Living Will
Do Not Resuscitate Statement/MOLST

Medical Information

During your stay with us you will be followed by a St. John's physician. With your permission our doctors may consult with your primary care physician or specialist.

Primary Care Physician

Primary Care Physician Address

Primary Care Physician Phone

Surgeon or Specialist

Surgeon or Specialist Address

Surgeon or Specialist Phone

Other

Other Address

Other Phone

Mental Health Specialist

Mental Health Specialist Address

Mental Health Specialist Phone

Ophthalmologist

Ophthalmologist Address

Ophthalmologist Phone

Financial Representative

To whom bills should be sent

First Name*

Last Name*

Address*

City*

State*

Zip*

Relationship*

Home Phone*

Work Phone

Cell Phone

Is a Trust fund involved

Yes No

Has a Conservatorship/Guardian been appointed?

Yes No

Has there been any transfer of funds or assets, including but not limited to real estate after 2/8/2006

Yes No

If yes, please explain

If yes, please provide name and when

Financial Information

If married, please provide information for spouse

Monthly

Salary: Applicant

Salary: Spouse

Social Security: Applicant

Social Security: Spouse

Retirement: Applicant

Pension: Spouse

Veteran's Pension: Applicant

Veteran's Pension: Spouse

Interest: Applicant

Dividends: Spouse

Specify other income sources...

Source 1

Applicant

Spouse

Source 2

Applicant

Spouse

Source 3

Applicant

Spouse

Total Monthly Income: Applicant

Total Monthly Income: Spouse

Assets

Does the applicant/spouse own a house or property?

Yes No

House Value

Property Value

Life Insurance (Cash Value)

Approx. Value

Pre-Paid Funeral Expense

Approx. Value

Checking Account

Approx. Value

Savings Account or CD

Approx. Value

Total Assets

Additional Financial Information

Additional information/comments which may be helpful in processing this application

General Information

Is there a social worker, case manager or community agency assisting with nursing home placement?

Yes No

Security Check*

Admissions Application

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