Admissions Form

Applicant Name *

Date of Birth *

Please indicate below the amount of INCOME you receive from each of the following sources and the frequency of Income received (weekly, monthly, quarterly, annually).

Source of Income

Social Security

Amount

Frequency Income Received

Supplemental Security

Amount

Frequency Income Received

Interest Income

Amount

Frequency Income Received

Dividend Income

Amount

Frequency Income Received

Pension

Amount

Frequency Income Received

Annuity

Amount

Frequency Income Received

Support from Relatives

Amount

Frequency Income Received

Other

Amount

Frequency Income Received

Other

Amount

Frequency Income Received

Please indicate below the approximate market value of each of the following assets you own:

Cash - Checking Account

VALUE IN DOLLARS

From

To

Cash - Savings Account

VALUE IN DOLLARS

From

To

Certificate of Deposit

VALUE IN DOLLARS

From

To

Securities - Stocks / Bonds / Mutual Funds

VALUE IN DOLLARS

From

To

Notes & Contracts Receivable

VALUE IN DOLLARS

From

To

Life Insurance (Cash Surrender Value)

VALUE IN DOLLARS

From

To

Personal Property (Auto, Jewelry, etc.)

VALUE IN DOLLARS

From

To

Retirement Funds (ex: IRA's, 401K)

VALUE IN DOLLARS

From

To

Real Estate (Market Value)

VALUE IN DOLLARS

From

To

Other Assets

VALUE IN DOLLARS

From

To

Other Assets

VALUE IN DOLLARS

From

To

Current Debt (Credit Cards, Accounts)

VALUE IN DOLLARS

From

To

Notes Payable

VALUE IN DOLLARS

From

To

Taxes Payable

VALUE IN DOLLARS

From

To

Real Estate Mortgages

VALUE IN DOLLARS

From

To

Other Liabilities

VALUE IN DOLLARS

From

To

Other Liabilities

VALUE IN DOLLARS

From

To

Total Liabilities

VALUE IN DOLLARS

From

To

Net Worth

VALUE IN DOLLARS

From

To

The financial information on this form is a true and correct statement of my current financial position to the best of my knowledge and belief. I further attest that U have not transferred, or donated, to another person's assets which are not reflected on this form within the past 5 years.

Full Name *

Date

Please answer all questions as completely and accurately as possible. This information is important for admission to Groton Community Health Care Center, Inc. and will be held in the strictest confidence.

Last Name *

First Name *

Middle Name

Date of Birth

Social Security Number

Sex

Male

Female

Marital Status

Religious Preference

Current Address *

Type of Address

Home

Adult Home

Nursing Home

Hospital

Other

Other Type Address

Reason for Admission Request

Physician Name

Phone

Address

Hospital Preference

Cortland Regional Medical Center

Cayuga Medical Center

Other

Other Hospital

Funeral Home Preference

Private Payment:

The responsible party indicates adequate funds to pay for applicant's care for a period of at least months. This in no way infringes upon the applicant's right to apply and/or become eligible for third party payment.

Medicaid:

Recipient Identification Number

Responsible County

Other Long Term Care Insurance:

Name of Insurance

Policy Number

Phone

Do you have a Medicare Advantage plan?

Yes

No

Plan Type

Medicare Number

Medicare Part A

Yes

No

Medicare Part B

Yes

No

Medicare Part D

Yes

No

Prescription Drug Plan

ID Number

Name of Company

ID Number

Policy Number

Phone Number

Veteran

Applicant

Spouse

VA File Number

Person to Contact Regarding this Application

Complete Address

Telephone Number:

Home

Work

Cell

Email

Power of Attorney/Person handling Finances/ Responsible Party for Payment

Name

Complete Address

Telephone Number:

Home

Work

Cell

Email Address

Health Care Agent

Complete Address

Telephone Number:

Home

Work

Cell

Email Address

List Children and their Addresses

List any Significant Others

Name of Applicant/ Responsible Party*

Date