Admission Application

First Name

Middle Name

Last Name

Address

City State Zip

Phone -

E-mail Address

Birth Date

Sex: Male Female

Marital Status

Birth Place

Social Security No.

US Citizen: Yes No

If Not, Provide Alien Registration Number

Religion

Church/Synagogue/Temple

Pastor/Rabbi

Present Location of Applicant

Previous Hospital Stay: Yes No From To

Hospital of Choice

Previous Nursing Home Stay: Yes No From To

Name of Nursing Home

Reason

Prior to Admission Status: Home Alone Home With Assistance :specify

Services of a Home Healthcare Agency: Yes No :Name

Major Health Concern

Most Recent Occupation

Accomidation desired: Ridge View Manor Sherdian Manor Williamsville Suburban

	Private Deluxe Room	Private Room
	Semi-Private	Suite (Sherdian Manor Only)

Personal Physician

Address

Telephone Number

Spouse's Information:

Spouse Name

Veteran: Yes No

Spouse's Social Security No.

Spouse's Birth Date

Spouse's Status: Living Deceased (Date of Death)

Responsible Party:

Name

Address

Relationship

Home Phone

Work Phone

Bank Power of Attorney: Yes No

Durable Power of Attorney: Yes No

Committee of Estate: Yes No

Conservatorship: Yes No

Guardianship: Yes No

Social Security No.

Living Children: (names, addresses, and phone numbers of all imediate family members)

Name

Address

Home Phone

Work Phone

Name

Address

Home Phone

Work Phone

Name

Address

Home Phone

Work Phone

Name

Address

Home Phone

Work Phone

Funeral Arrangments:

Prepaid Funeral Arrangment: Yes No

If Yes, Amount of Burial

Name of Funeral Home

Address

Phone

In the Event of an Emergency, Notify,

Name

Relation

Address

Home Phone

Work Phone

Insurance Coverage:

Medicare No.

Part A

Part B

Eff Date

Medicaid No.

Type

Eff Date

Case Worker's Name

County

Veteran's Benefit

Other Private Medical Insurence (Name, Identification Number, Contact Phone Number)

Prescription Coverage: Yes No

Policy Name

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

Monthly Income

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

Assets

Owns Real Estate: Yes No

Approxmite Value
(copy of deed is needed)

If yes, occupied by

Who owns the house?

Is the property rented?: Yes No

Is the house to be sold?: Yes No

Who is the real estate agent?

Life Insurance: Yes No

If Yes, name, value, account numbers of all policies)

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

Is there a will? Yes No

Is there a family attorney? Yes No

If yes, name, address, and phone number

Has there been any transfer of assets in the past 60 months? Yes No

If yes, how much, when and to whom were the assets transferred?

Any other property, car, motor home, summer home, etc.? Yes No

Any other assets? Yes No

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

Other Financial Information (specify)

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.