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Upcoming Events

Friday, March 12 9:00 AM
MORNING PRAYER, Chapel/Ch.12
Friday, March 12 3:15 PM
MOVIE TIME Ch.12
Saturday, March 13 9:00 AM
MORNING PRAYER, Chapel/Ch.12
Partial Calendar Of Events
             List of All Activities

Admission Application


Applicant Demographics
*First Name: *MI:
*Last Name:
*Home Address:
*City:
*County:
Date of Birth: (MM/DD/YYYY)
Gender: Male Female
Home Phone: (555-555-5555)
Work Phone: (555-555-5555)
Cell Phone: (555-555-5555)

Marital Status:
Religion:
Name of Church or Synagogue:
U.S. Citizen? Yes
No
Are either you or your spouse
a United States Veteran?
Yes
No
*Current location of applicant:
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
First Name
Last Name
Relationship:
Address
City
State:
Zip:
Home Phone: (555-555-5555)
Cell Phone: (555-555-5555)
Business Phone: (555-555-5555)
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.
Name of funeral home:*
Phone:*
*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.

Financial Representative
To whom bills should be sent

*First Name:
*Last Name:
*Address:
*City:
*State:

*Zip:
*Relationship:
*Home Phone: (555-555-5555)
Work Phone: (555-555-5555)
Cell Phone: (555-555-5555)
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

Financial Information
If married, please provide information for spouse
Monthly
Salary: Applicant: $
Spouse: $

Social Security: Applicant: $
Spouse: $

Retirement Pension: Applicant: $
Spouse: $
Veteran's Pension: Applicant: $
Spouse: $
Interest / Dividends: Applicant: $
Spouse: $

Other Income: Specify other income sources...
Source 1:

Applicant: $
Spouse: $
Source 2:

Applicant: $
Spouse: $
Source 3:

Applicant: $
Spouse: $
Total Monthly Income: Applicant: $
Spouse: $


Assets
Does the applicant own a home?: Approx. Value: $
Life Insurance
(Cash Value):		 Approx. Value: $
Pre-Paid Funeral Expense: Approx. Value: $ Where?
Checking Account: Approx. Value: $
Savings Account or CD: Approx. Value: $
Total Assets: $


Additional Financial Information
Please add any 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

 

To learn more about all St. John's Home has to offer, simply click on the schedule a visit button, or feel free to call Social Work Services at 585-271-0720 or send an email to info@stjohnshome.com. We encourage you to frequently revisit our web site, for the latest information about all of our programs, special events, and "everything St. John's."