RAHSA - Online Application Form

This form serves as a preliminary application for all RAHSA homes. Additional information may be necessary for individual nursing homes. These homes will contact you after receiving this application.

Fields marked with an asterisk * are required.

*Please check the nursing homes that you want to receive this application:

Episcopal Seniorlife Communities	Fairport Baptist Homes Caring Ministries	Family Service of Rochester
Hill Haven	Jewish Home of Rochester	Lakeside Beikirch Care Center
Monroe Community Hospital	Rochester Presbyterian Home	Seniorsfirst (Kirkhaven & Valley Manor)
St. Ann's Community	St. Johns Senior Communities	The Friendly Home
The Highlands at Pittsford	The Wesley Community	Unity Health System

Applicant Demographics

*First Name:

*MI:

*Last Name:

*Home Address:

*City:

*County:

Date of Birth:

(MM/DD/YYYY)

Gender:

Male Female

Home Phone:

(555-555-5555)

Work Phone:

(555-555-5555)

Cell Phone:

(555-555-5555)

Marital Status:
Spouse's Name:
Date of Marriage:	(MM/DD/YYYY)
If deceased, when?:	(MM/DD/YYYY)
Religion:
Name of Church or Synagogue:
U.S. Citizen?	Yes No
If naturalized US citizen, date of naturalization:	(MM/DD/YYYY)
Are either you or your spouse a United States Veteran? Yes No
*Current location of applicant:
If applicant is currently hospitalized or has been hospitalized within the past 30 days, complete the following:
Name of hospital:
Dates of stay:
Reason for hospitalization:
Has the applicant had a previous nursing home stay? Yes No
If yes, please give the facility names and dates:
Please list names of physicians including specialist and dentist

Insurance Coverage
Social Security Number:	(000-00-0000)
Medicare #:
Blue Cross #:
Type of plan:
Blue Choice #:
Type of plan:
Preferred Care #:
Type of plan:
Medicaid #:
Medicaid County:
Case Worker Name:
Case Worker Phone:	(555-555-5555)
Other Insurance #:
Long Term Care Insurance?	Yes No
If yes, please provide and contract #:
Additional Insurance Information

Primary Contacts
First Name
Last Name
Relationship:
Address
City
State:	Zip:
Home Phone:	(555-555-5555)
Work Phone:	(555-555-5555)
Cell Phone:	(555-555-5555)
Does the applicant have a Health Care Proxy?:	Yes No If yes, please provide copies at the time of admission.
Have Advance Directives been established (Living Will, DNR?:	Yes No If yes, please provide copies at the time of admission.
Name of funeral home:*
Phone:*
*This information must be on file, according to regulations, with at least a preference, if arrangements have not been made.� Copies of all cards must be provided upon admission.

Financial Representative manages financial obligations of applicant
*First Name:
*Last Name:
*Address:
*City:
*State:	*Zip:
*Relationship:
*Home Phone:	(555-555-5555)
Work Phone:	(555-555-5555)
Cell Phone:	(555-555-5555)
Does this person have Power of Attorney? (If yes, please provide copy of the Power of Attorney at the time of admission):	Yes No
Is a Trust fund involved:	Yes No
Has a Conservatorship/Guardian been appointed?:	Yes No
Has there been any transfer of funds or assets, including but not limited to real estate in the past 36 months:	Yes No
If yes, please explain:
Have you consulted with an attorney or financial advisor regarding payment for nursing home care?:	Yes No
If yes, please provide name:

Financial Information If married, please provide information for spouse
Monthly
Salary:	Applicant: $ Spouse: $
Social Security:	Applicant: $ Spouse: $
Retirement Pension:	Applicant: $ Spouse: $
Veteran's Pension:	Applicant: $ Spouse: $
Interest / Dividends:	Applicant: $ Spouse: $
Other Income:	Specify other income sources...
Source 1:
	Applicant: $ Spouse: $
Source 2:
	Applicant: $ Spouse: $
Source 3:
	Applicant: $ Spouse: $
Total Monthly Income:	Applicant: $ Spouse: $

Assets
Does the applicant own a home?:	Approx. Value: $
Life Insurance (Cash Value):	Approx. Value: $
Pre-Paid Funeral Expense:	Approx. Value: $
Checking Account:	Approx. Value: $
Name of bank:
Savings Account or CD:	Approx. Value: $
Name of bank:
Stocks and Bonds:	Specify which Stocks and Bonds...
	Source 1:
	Approx. Value 1: $
	Source 2:
	Approx. Value 2: $
	Source 3:
	Approx. Value 3: $
Total Assets:	$


Additional Financial Information
Please add any additional information/comments which may be helpful in processing this application:

General Information
Is there a social worker, case manager or community agency assisting with nursing home placement?:	Yes No
First Name:
Last Name:
Agency:
Work Phone:	(555-555-5555)

Consent for release of information to RAHSA Member Nursing Homes I hereby give my permission for any and all physicians, dentists, social workers, psychologists, nurses, technicians, clinics, hospitals , and psychiatric facilities where I have been a patient to provide requested medical information to the nursing facilities that I have indicated on this form.
Name of Applicant:
Relationship to Applicant:
Date:	(MM/DD/YYYY)