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The British Home Community

VIEWS: 4 PAGES: 10

									8700 West 31st Street, Brookfield, IL 60513

Dear Applicant and/or Family Member:

Thank you for choosing The British Home’s Medicare-Certified Skilled Nursing and
Rehabilitation Facility (SNF). If you have questions about our application forms, please
contact us directly at (708) 485-1155 and our trained admissions staff will assist you.

Please complete the following documents that make up our application packet. Return them
in person or via fax to the Admissions Office at The British Home, fax number (708) 485-8830:

         Application Form
         Authorization for Release of Information
         Admission Screening Disclosure and Release
         Telephone Election Form

We also need copies of the following documents to be returned with your application packet:

         Medicare Card
         Supplemental Health Insurance Card
         POA Health Care
         Living Will
         DNR

We look forward to your arrival at The British Home.

Thank you,
The Admissions Staff of The British Home




                                                                                            1
                       8700 West 31st Street, Brookfield, Illinois 60513-1097
                      708-485-1155 Fax: 708-485-8830 www.thebritishhome.org
                         A not-for-profit organization, and a smoke-free campus

                                         Application Form

Please print or type in permanent ink. The information contained in this application will be kept
confidential and used solely for the purposes of The British Home Community.

I hereby make application to the following (please check one):

_____ Wye Valley (Independent Living) Circle apartment size preference: 1BR Larger 1BR    2BR
_____ The Woodlands (Assisted Living) Circle apartment size preference: Studio 1BR        2BR
_____ The Laurels (Private Sheltered Care Studios)
_____ Medicare-Certified Skilled Nursing and Rehabilitation _____ Nursing Center (Private Pay)

APPLICANT:

_________________________________________________________________________________________
Last Name                           First Name                    Middle Name

________________________________________________________________________(_____)___________
Street Address                      City        State       Zip Code    Telephone

_________________________________________________________________________________________
Social Security Number             Medicare Number (or comparable railroad insurance number)

_________________________________________________________________________________________
Date of Birth                           Birthplace

Number of years at present address: _________

Present living arrangement (circle appropriately): Own Home Own Condo/Townhouse Rent
                                                   Live with Family Other
If other, explain:__________________________________________________________________________

Marital status (circle appropriately):   Never Married Married     Widowed        Separated   Divorced

Are you a citizen of the U.S.? (circle) Yes   No     Are you a veteran? (circle) Yes     No

Race/Ethnicity (circle): American Indian/Alaskan Native     Asian/Pacific Islander
Black, not Hispanic      Hispanic    White, not Hispanic    Other:___________
Primary Language Spoken:_________________________________________________________________

                                                                                                     2
Name of Father: ___________________________________Birthplace: _____________________________

Maiden Name of Mother:___________________________Birthplace:______________________________


SPOUSE:
__________________________________________________________________________________________
Name                                       Maiden Name

PREVIOUS OCCUPATION/EDUCATION

Most recent occupation:
__________________________________________________________________________________________
Company                                               Position

Education (Mark highest level completed)
___No schooling     ___8th grade/less ___9-11 grades     ___High school
___Technical or trade school     ___Some college   ___Bachelor’s degree          ___Graduate degree

PASTORAL CARE

What is your religious affiliation (denomination) if any?______________________________________

Of what church are you a member? _________________________________________________________

_____________________________________________________(_______)____________________________
Clergy Contact                                        Telephone Number

_________________________________________________________________________________________
Church Street Address                           City              State       Zip Code

Do you wish Clergy to be called in case of emergency? (circle)        Yes   No   No Preference

Do you have any prearranged funeral arrangements?_________________________________________

INSURANCE

Do you have Supplemental Health Insurance? (circle)    Yes       No

_________________________________________________________________________________________
Policy Name                         Group Number                        ID Number

Do you have Long Term Care Insurance? (circle) Yes     No        Policy Name: _____________________



                                                                                                  3
ADVANCE DIRECTIVES

Do you have a Living Will?                Yes   No                Please attach copy

Do you have Durable Powers of Attorney?

            for Healthcare?               Yes   No                Please attach copy

            for Property/Finances?        Yes   No                Please attach copy


CONTACTS IN CASE OF EMERGENCY (Please list in the order of how they will be called):

1)________________________________________________________________________________________
      Name                                            Relationship

__________________________________________________________________________________________
      Street Address                      City              State             Zip Code

__________________________________________________________________________________________
      Home Phone #                  Work Phone #            Cell Phone #      E-mail


2)________________________________________________________________________________________
      Name                                            Relationship

__________________________________________________________________________________________
      Street Address                      City              State             Zip Code

__________________________________________________________________________________________
      Home Phone #                  Work Phone #            Cell Phone #      E-mail


3)________________________________________________________________________________________
      Name                                            Relationship

__________________________________________________________________________________________
      Street Address                      City              State             Zip Code

__________________________________________________________________________________________
      Home Phone #                  Work Phone #            Cell Phone #      E-Mail



                                                                                         4
MEDICAL INFORMATION

__________________________________________________________________________________________
Name of Primary Care Physician      Office Phone Number                 Hospital Affiliation

__________________________________________________________________________________________
      Street Address                      City              State             Zip Code

__________________________________________________________________________________________
Name of Other Physician             Office Phone Number                 Hospital Affiliation

__________________________________________________________________________________________
      Street Address                      City              State             Zip Code

__________________________________________________________________________________________
Name of Dentist                     Office Phone Number                 Hospital Affiliation

__________________________________________________________________________________________
      Street Address                      City              State             Zip Code

Your Hospital Preference:__________________________________________________________________


PERSONAL INFORMATION

If bills should be sent to someone other than the resident, please identify person below:

__________________________________________________________________________________________
Name                                            Relationship

__________________________________________________________________________________________
Street Address                      City              State             Zip Code

__________________________________________________________________________________________
Home Phone #                  Work Phone#                   Cell Phone #      E-mail

Do you plan to bring any automobiles?      Yes      No        If yes, please complete the following:

Make___________ Model__________ Year______ Color__________ License Plate Number__________

I hereby certify to the best of my ability that the above information is correct.

____________________________________________         ___________________________________________

                                                                                                       5
                Applicant’s Signature                                                                  Date

PLEASE NOTE: It is the policy of The British Home to complete a standard criminal background/sexual offender check on all persons
making application to the Health Care and Medicare Rehabilitation Center or the Laurels Sheltered Care sections of The British Home
campus. The background check is done by comparing the applicants’ names to state/federal databases.                 Revised: 11/2007




                                                                                                                                   6
                        HEALTHCARE ADMISSION SCREENING
                            DISCLOSURE AND RELEASE

Dear Applicant/Representative:

In connection with my application for residency to The British Home:

I hereby fully release and discharge The British Home, their respective affiliates, subsidiaries,
directors, officers, employees, agents and attorneys thereof, and each of them, and any individual,
organization, entity, agency, or other source providing information to the above named company
from all claims and damages arising out of any investigation of my background for residency at The
British Home.

Due to state regulations, it has become a policy of The British Home to complete a standard criminal
background/sexual offender check on all persons making application to the Health Care and
Medicare Rehabilitation Center or the Laurels Sheltered Care section(s) of the home campus. This
background check is done by comparing the applicant’s names to state databases.

A copy of the summary of the rights of the consumer pursuant to Fair Credit Reporting Act (FCRA) is
available upon request, and I have also been provided a disclosure that an investigative consumer
report will be sought pursuant to FCRA. I hereby authorize and give my consent to The British Home
for the procurement of consumer report(s).

In view of the above, please complete the information below and return to the Admissions Office as
soon as possible so that we may continue with the screening process.

FOR PURPOSES OF GATHERING THIS INFORMATION, I AGREE TO SUPPLY THE FOLLOWING
INFORMATION:


______________________________                        ______________________________
Print Applicant’s Name                                Applicant’s Signature

_____________________________                  ______________________________
 Social Security Number                              Date of Birth


Male _________             Female ________            Race________




                                                                                                       7
                  AUTHORIZATION FOR RELEASE OF INFORMATION


I hereby authorize                                                           to release the following
                  (name of facility from which you are requesting records)

information on:                                                               to The British Home.
                                     (patient’s full name)

Patient’s full address:____________________________________________ ________________


Patient’s SSN:                                       Patient’s Date of Birth:


Records for the period (dates) from:                                           to

____   Face Sheet               ____ Medication List
____   Discharge Summary        ____ History and Physical
____   Consultation Notes       ____ Laboratory Report
____   Therapy Notes            ____ X-ray/Radiology Report
____   Progress/Physician Notes ____ Pathology Report
____   Other________________________________________

I understand that this consent is effective until the patient/resident’s discharge date from The British
Home unless consent is revoked earlier in writing. The patient/resident and/or the
patient/resident’s legal representative have a right to inspect a copy of the health information
released to The British Home by the facility named above. Health Information released to The British
Home is held to the strictest privacy standards in accordance with state and federal laws.



Printed Name of Resident and/or Resident Representative



Signature of Resident and/or Resident Representative                          Date

Please Return To: Mary P. Allen, RN, Director of Admissions for The British Home
                  Dedicated, Private Fax: (708) 485-8830 Phone: (708) 485-3059
                                                                                                        8
Dear Resident and/or Resident Representative:

Unless you the resident and/or your representative decline in writing, residents of the
Healthcare and Rehabilitation Center of The British Home are provided with a bedside
telephone on the day of admission to our facility.

The charge for telephone service is $1 per day, and this amount will be reflected on
your monthly statement. Medicare does not cover charges for telephone service.

Please indicate if you wish to have a phone at your bedside, sign below, and return
this form with your application materials to our admissions office.
________________________________________ ____


______     I wish to have a telephone at my/my family member’s bedside


______     I do not wish to have a telephone at my/my family member’s bedside



Print Resident’s name_______________________________________________________


Resident’s signature_____________________________________________________________

(and/or)

Print Resident Representative’s name______________________________________

Resident Representative’s signature______________________________________




                                                                                       9
                                 Helpful Hints for
                                Your Rehabilitation Stay
Thank you for choosing The British Home’s Skilled Nursing and
Rehabilitation Services. Here are some helpful hints for your stay:


Please bring about one week’s worth of comfortable daytime clothing with your name written inside.
Laundry markers can be purchased at Walgreens, CVS, etc. or you can ask us to borrow one. We will
launder your clothing at no charge.

Also bring two pairs of pajamas and/or nightgowns, a comfortable robe and one week’s worth of
undergarments. You may also bring rubber-soled slippers.

Please bring a comfortable pair of rubber-soled street shoes to wear to your therapy sessions. The
right shoes are very important to your rehabilitation and recovery.

You should also bring any puzzles, books, magazines, laptop computers, hand-held video games or
other such portable things you enjoy and would like to catch up on.

Leave behind any checkbooks, credit cards and/or cash. Anything additional that you need to
purchase while you are here we can bill you for at a later date.

Please wear a minimal amount of jewelry and leave other valuables behind. However, if you have
valuables with you, let the Admissions Staff know, and we will lock it up.

Please do not bring food. Meals and snacks are provided. Food gifts from family or friends should
be cleared through the Charge Nurse before being consumed.

Your call button should always be within your reach. Please keep it clipped to your bed where you
can reach it to call the nurses or aides. We want to know you are calling us.

We currently use outside services for vision, dental, audiology and podiatric care.
The following vendors can provide service to you during your stay. It is your responsibility, or the
responsibility of your representative to contact providers directly.

      Geriatric Vision Care                           Phone:          (312) 829-0956
      Precision Audiology                             Phone:          (630) 926-5368
      Dr. Allan C. Katz, DDS, Dentist                 Phone:          (630) 837-5969
      Dr. Nikola Ivancevic, DPM, Podiatrist           Phone:          (708) 547-9322




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