Healthcare Residential Care Application

HEALTHCARE RESIDENTIAL CARE APPLICATION

Facility and Application Information

Facility Name:   Date of Application:

Applicant / Patient Information

Date of Birth:   Gender: Male Female Other

Emergency Contact

Responsible Party / Guarantor

Insurance and Payment Information

Payment Source (check all that apply): Private Pay Medicare Medicaid Other

Medical History and Current Health Status

Mobility Status: Independent Cane Walker Wheelchair Bedbound

Cognitive Status: Oriented Memory Loss Dementia Other

Advance Directives and Special Instructions

Does the applicant have an advance directive, living will, or healthcare power of attorney? Yes No

Do-Not-Resuscitate (DNR) order on file? Yes No

Authorizations, Consents and Acknowledgments

Consent for Admission and Routine Care: By signing below, the applicant authorizes the facility to provide admission and routine ongoing residential care, nursing, personal care, social services, therapies, and medication administration as ordered by licensed practitioners. The applicant understands applicable risks associated with care and may revoke consent at any time in writing; revocation will not affect care provided prior to receipt of revocation.

Authorization to Obtain and Release Medical Information: The applicant authorizes release of medical, behavioral and insurance information to the facility and to third parties as required for treatment, payment and healthcare operations. This authorization includes records from hospitals, physicians, pharmacies, and other providers. This authorization shall remain in effect until: unless earlier revoked in writing.

Emergency Medical Treatment: If the applicant requires immediate medical attention and the facility cannot contact the responsible party in a timely manner, the facility is authorized to obtain emergency medical treatment as deemed necessary by attending clinicians. The facility shall make reasonable attempts to notify the responsible party and emergency contact.

Financial Responsibility: The responsible party agrees to be financially responsible for charges for care, services and supplies furnished by the facility that are not paid by insurance or other third-party payors. The facility may pursue collection for balances due. The applicant acknowledges that eligibility for public benefits is the responsibility of the applicant and responsible party to obtain and maintain.

Privacy Notice and HIPAA Acknowledgment: I acknowledge that I have been provided an opportunity to receive the facility's privacy notice describing uses and disclosures of protected health information. I understand that the facility will protect my health information in accordance with applicable law and may disclose information to other providers, payors, and family members as permitted by law and this application.

Admission Criteria and Conditions: The facility will assess the applicant's needs and determine appropriateness for admission based on medical, behavioral and safety considerations. Admission may be deferred or terminated if the facility cannot safely meet the applicant's needs, or if the applicant's condition or behavior presents immediate risk to self or others.

Truthful Disclosure: The undersigned certifies that the information provided in this application is true and complete to the best of their knowledge. Failure to disclose pertinent medical, behavioral, or financial information may result in denial of admission or subsequent discharge for cause.

Acknowledgments (select)

I acknowledge receipt of the facility's privacy notice and understand my rights regarding protected health information.

I understand my financial responsibility for services not covered by insurance or other payors.

Additional Information

Certification and Signature

By signing below, I certify that I am the applicant or legal guardian/authorized representative of the applicant. I authorize the facility to obtain and use health and insurance information as described above and accept the financial and other terms stated in this application.

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