ADMISSIONS APPLICATION

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					                               ADMISSIONS APPLICATION

Patient’s Name ________________________________________________________________
Current Address _______________________________________________________________
Birth Date _____________________Sex _________ Age______ Marital Status_____________
Birthplace___________________________________Religion___________________________
Education/Degree __________________________Previous Occupation___________________
Spouse’s Name________________________________________________________________
Father’s Name ________________________Mother’s Maiden Name _____________________
Social Security Number ____________________Medicare Number ______________________
Other Health Insurance ___________________________ Number _______________________
Personal laundry (check one) Facility ________________ Family ________________________
Funeral Arrangements __________________________________________________________
Will patient be Medicaid Eligible within 6 months: Yes or No _____________________________
DSS Office _______Eligibility Worker _____________________Medicaid Number ___________
Point of Contact’s name _________________________________________________________
Relationship to the Patient _______________________________________________________
Point of Contact’s Address _______________________________________________________
Home Phone _________________________ Work Phone ______________________________
Power of Attorney?                                    Yes     No
Does Patient have a Living Will or Advance Directive?     Yes       No
Second person to notify in case of emergency _______________________________________
Relationship to patient __________________________________________________________
Home Phone _______________________________Work
Phone______________________________
=========================================================================
Patient Now at: Home _______ Adult Home _______ Nursing Home ______Hospital _________
Other _______________________________________________________________________
Name of Hospital or Facility ______________________________________________________
Social Worker _________________________________________________________________
Patient’s Physician _____________________________________________________________
How were you referred to Stoddard Baptist Nursing Home?_____________________________
____________________________________________________________________________



         1818 Newton Street, N.W.  Washington, D.C. 20010  (202) 328-7400
                              FINANCIAL APPLICATION
Correct information is essential for providing a solution to any future contingencies
relating to qualifying for Medicare or Medicaid status.


1.    How long does the patient plan to reside at Stoddard Baptist Nursing Home?

      ______________________________________________________________________

2a.   Names of persons who will be financially responsible for the patient’s cost of care:

      ______________________________________________________________________
      Name                       Address                  Home Phone Number

2b.   Has a trust account been established or a power of attorney conferred on the persons to
      be financially responsible? ____Yes     ____No

2c.   If “yes” please provide us with a copy of the trust document or the document granting
      power of attorney. If the trustee or the individual exercising the power of attorney is
      other than a person in (2a), please give his or her name.

      ______________________________________________________________________
      Name                       Address                   Home Phone Number

      ______________________________________________________________________
      Name                       Address                   Home Phone Number

3.    Is the patient physically and/or mentally capable of handling his or her own affairs?
      ____Yes        ____No

      If not, has a guardian or committee been appointed? ____Yes          ____No

      ______________________________________________________________________
      Name                       Address                   Home Phone Number

      ______________________________________________________________________
      Name                       Address                   Home Phone Number

      State the court in which he/she was so appointed?

      ______________________________________________________________________

4.    Please show the assets and sources of income available to help pay the cost of care:

      (A)    Real Estate
      Location           Estimated          Annual               Balance on
                         Market Value       Rental Income        Mortgage
      ______________________________________________________________________
      ______________________________________________________________________
      ______________________________________________________________________

      ______________________________________________________________________
(B)   Checking Accounts:

      Bank and Account#                                          Current Balance
      _____________________________________________________________________________
      _____________________________________________________________________________
      _____________________________________________________________________________


(C)   Savings Accounts:

      Bank and Account#
      _____________________________________________________________________________
      _____________________________________________________________________________
      _____________________________________________________________________________


(D)   Stocks, Bonds, Securities:

      Name                         Estimated                     Annual Interest
                                   Value                         Dividends
      _____________________________________________________________________________
      _____________________________________________________________________________
      _____________________________________________________________________________


(E)   Pension, Annuities, IRA:

      Source                       Estimated                     Monthly
                                   Current Value     or          Income
      _____________________________________________________________________________
      _____________________________________________________________________________
      _____________________________________________________________________________


(F)   Social Security:
      Monthly Benefit
      _____________________________________________________________________________


(G)   Insurance Policies:                                       Estimated Present
      Insurance Company            Beneficiary                  Cash Value

      _____________________________________________________________________________
      _____________________________________________________________________________
      _____________________________________________________________________________


(H)   Sources other than above:
      _____________________________________________________________________________
      _____________________________________________________________________________
      _____________________________________________________________________________
(I)    Notes Due                                      $____________________________________
       Account                                        $____________________________________
       Loans Due                                      $____________________________________
       First or Second Trust Held                     $____________________________________



5.     Has the patient transferred any assets over $5000 in value such as real estate, stocks,
       bonds or other assets to another person without consideration?

       In the last 24 months? ____Yes  ____No (If yes please explain)
       ______________________________________________________________________
       ______________________________________________________________________
       ______________________________________________________________________


6.     Fill out if patient is on Medicare:
       Do you plan to have the patient remain in the nursing home after Medicare benefits are
               exhausted?
       ____Yes          ____No

       (If no where will the patient go?)
       ______________________________________________________________________
       ______________________________________________________________________


7.     Have you or anyone in the past two years made application for this person to be on
       Medicaid?

       ____Yes         ____No         (If yes please explain)

       Have you filed an appeal?        ______Yes ______No                   Date________________


*Incorrect information on this application can result in the potential client being ineligible for Medicaid.


       ___________________________________                           _____________________________
       Name of Person Completing Application                         Applicants Name

       ___________________________________
       Date
                                Rate Schedule
                             Effective April 1, 2007
Room Board and Routine Nursing Care

      Intermediate/Skilled                     $280.00 per day

Physical Therapy

      Evaluation                               $ 50.00 per unit (15 minutes)
      Treatment                                $ 50.00 per unit (15 minutes)

Occupational Therapy

      Evaluation                               $ 50.00 per unit (15 minutes)
      Treatment                                $ 50.00 per unit (15 minutes)

Speech Therapy

      Evaluation                               $ 50.00 per unit (15 minutes)
      Treatment                                $ 50.00 per unit (15 minutes)

Clinitron Bed and Supplies                     $ 200.00 per day
        Mattress Overlay                       $ 15.00 per day

Pharmaceuticals                                  Billed as used

Medical Supplies                                 Billed as used

Transportation

      Wheel chair van                          $ 50.00
      Taxi                                     $ 15.00
      Escort Fee                               $ 15.00




Rev. 3/30/07

       1818 Newton Street, N.W.  Washington, D.C. 20010  (202) 328-7400
FINANCIAL ITEMS/DOCUMENTS NECESSARY FOR ADMISSIONS

Dear Applicant:

In order for you to be approved financially, please provide the Admissions Department
with the following items and documents below that are applicable.

      Statements/Verification of income:
_____ Bank or other asset statements covering the past month
_____ Social Security Administration
_____ Supplemental Security Income
_____ Veterans Administration
_____ Civil Service Administration
_____ Pension or Other Retirement

      Verification of Insurance:
_____ Social Security Status Report
_____ Medicare Card (not copy)
_____ Medicare Part D
_____ Medicaid Card
_____ Social Security Card
_____ Birth Certificate
_____ Blue Cross Blue Shield Card
_____ Aetna Card
_____ Long Term Care Policy
_____ Life Insurance Policy
_____ Other insurance information: __________________________
_____ Funeral and Burial Pre-Arrangement (if applicable)
_____ Current Statement of Burial Account (if applicable)
_____ Documents of Life Insurance for funeral and burial
_____ Property
__________________________________________________________________


Other Information:
_______________________________________________________________________
_______________________________________________________________________




         1818 Newton Street, N.W.  Washington, D.C. 20010  (202) 328-7400

				
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