|
To apply to become a resident at St. Mary's Nursing Center, please
fill out the application below. If you have any questions or concerns, please
contact us at (301) 475-8000 or click here to fill
out our online contact form. |
| APPLICANT |
| Diagnosis: |
|
| First Name: |
|
| Middle Name: |
|
| Last Name: |
|
| City: |
|
| |
State:
, Zip Code:
|
| Date of Birth: |
|
| |
Age:
Sex:
, Marital Status:
|
| Religion/Race: |
|
| Social Security Number: |
|
| Veterans Status: |
|
| Medicare Number: |
|
| Medicaid Number: |
|
| Admitted from: |
|
|
RESPONSIBLE PARTY |
|
, Relationship:
|
| Address: |
|
| E-mail Address: |
|
| Home Phone (include area code): |
, Work Phone:
|
| Cell Phone (include area code): |
|
|
, Relationship:
|
| Address: |
|
| E-mail Address: |
|
| Home Phone (include area code): |
, Work Phone:
|
| Cell Phone (include area code): |
|
|
ADDITIONAL INFORMATION |
| Power of Attorney/Living Will: |
|
| Education: |
, Occupation:
|
| Place of Birth/Citizenship: |
|
| Patient aware of placement? |
|
| Attending Physician: |
|
| Allergies: |
|
| Mortuary Name: |
, Mortuary Phone:
|
| Laundry: |
|
| Secondary Insurance Information / ID Number: |
|
| Comments: |
|
Application Date: |
|
| Admission Date |
|
| Location: |
, Type:
|
| Patient Number: |
|
|
FINANCIAL QUESTIONAIRE |
| Applicant Name: |
|
| Income (enter monthly amounts) |
|
| Social Security: |
|
| Pension: |
, Company Name:
|
| VA Pension: |
, Claim #:
|
| Dividends and Interest: |
|
Other Monthly Inc
( rental, land contract, etc): |
|
| Assets |
|
| Balance of Checking Account (s): |
|
| Name and Address of Accounts: |
|
| Balance of Savings Account (s): |
|
| Balance of Certificates of Deposit and Other Securities: |
|
| Balance of Savings Bonds: |
|
| Balance of Stocks and Bonds: |
|
| 1. Company and Amount: |
|
| 2. Company and Amount: |
|
| Cash on Hand (Home, Safety Deposit Box): |
|
| Have any assets been sold/transferred/or disposed within five
years? |
|
| Real Estate |
|
| Ownership: |
|
| Does the applicant own real estate? |
|
| Location: |
|
| What is the approximate value of the property? |
|
| Are there any liens or judgments against the property? |
|
| Does the applicant own rental property? |
|
| If yes, list name and address: |
|
| LIFE INSURANCE |
Company: |
|
| Policy #: |
|
| Face Value: |
|
| Cash Surrender Value: |
|
| Beneficiary: |
|
| Other funds set aside for burial? |
Specify:
|
| Prepaid burial? |
|
| If yes, specify the amount and funeral home: |
|
| Does any party (other than the applicant) have access
and control of the aforementioned income/assets?
|
| If yes, please specify name and address: |
|
|
I hereby acknowledge that the information as provided herein is correct. Failure
to disclose accurate financial information may be grounds for legal action in
accordance with prevailing Federal, State, and Local Statutes and regulations. |
|
|
|