716-649-9111

5285 South Park Ave
Hamburg, Erie County 14075
USA

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Admission Application
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Sex:
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Are you a Citizen of the United States?
Previous Hospital Stay?
Previous Nursing Home Stay?
Prior Admission Status
Do You Use the Services of a Home Health Agency?
Accommodation Desired:
Have you ever been convicted of a Felony or a Misdemeanor?

Spouse Information​:

Is your Spouse a Veteran?

Responsible Party/ Spouse:

Bank Power of Attorney
Durable Power of Attorney?
Do You Have Guardianship?

Funeral Arrangements:​

Prepaid Funeral Arrangement:

Emergency Contact Information:​

Insurance Coverage​:​

Prescription Coverage
Do you have long-term supplemental insurance?

Financial Information (All information is considered confidential. Proof of all assets is required prior to admission)

Monthly Income:

Applicant

Spouse​

Assets:

Owns Real-Estate

Copy of the Deed is Need​ed

Is the Property Rented?
Is the House to be Sold
Life Insurance

Policy Info if Applicable

Policy Info if Applicable

Policy Info if Applicable​

Policy Info if Applicable​

Is there a family attorney?
Has there been any transfer of assets in the past 36 months?
Any other Property: Car, Motor Home, Summer Home, etc.?

Liabilities​

Home Mortgage
Loan/ Installments
Other Liabilities

As Representative, I will be responsible for payment of all expenses incurred by the applicant that are not covered by Medicare, Medicaid, or private health insurance. Payment will be made from the applicant's personal income or resources and I will not personally incur liability or expense. I certify that the information provided in this application is true, correct, and valid.