ADMISSION APPLICATION

* Indicates a required field.

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. *
  

 




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St. Mary's Nursing Center, Inc. • 21585 Peabody St. • Leonardtown, MD 20650TEL: (301) 475-8000 • FAX: (301) 475-3085
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