Sex: Male

US Citizen: Yes

Previous Hospital Stay: Yes

Previous Nursing Home Stay: Yes

Prior to Admission Status: Home Alone

Services of a Home Healthcare Agency: Yes

Accommodation desired:
Semi-Private Private Deluxe Room Private Room

Have you ever been covicted of a Felony or Misdemeanor? Yes No

Spouse's Information:

Veteran: Yes

Responsible Party/Spouse:

Bank Power of Attorney: Yes

Durable Power of Attorney: Yes

Guardianship: Yes

Funeral Arrangements:

Prepaid Funeral Arrangement: Yes

In the Event of an Emergency, Notify,

Insurance Coverage:

/Service Number

Prescription Coverage: Yes

Do you have long-term supplememental insurance? Yes No
If YES, Insurance Company:

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

Monthly Income

Monthly Income Applicant Spouse
Social Security
Supplemental Security Income
Retirement Pension
Veteran's Pension
Others (Specify)


Savings Account
Checking Account
Other (CD's, Money Market Fund, Trusts):

Owns Real Estate: Yes
If YES, please answer the following:
Address of real estate:

When was the property purchased? (year):

(copy of deed is needed)

Is the property rented?: Yes

Is the house to be sold?: Yes

Life Insurance: Yes

Name/Description Financial Institution Approx. Value Type/Account Number

Health Care Proxy:

Non-Hospital DNR:

Is there a family attorney? Yes

Has there been any transfer of assets in the past 36 months? Yes

Any other property, car, motor home, summer home, etc.? Yes

Liabilities Yes/No Approximate Value
Home Mortgage Yes
Loan/Installments Yes
Other Liabilities (specify) Yes

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.