Solomons Senior Living

 

Solomons Rehab and Care Center Resident Applicaton

To apply for admission to Solomons Rehab and Care Center, please complete the following application. This application will become part of the Resident Agreement and should be completed in its entirety. All information will be held in the strictest of confidence.

 

General Information:

Name of Prospective Resident:

Sex:

Male Female

Age:

Date of Birth:

Marital Status:

Single Married

Widowed Divorced

Street Address:

City:

State:

Zip Code:

E-mail Address:


An e-mail address is required.

Invalid e-mail address

Home Phone (please include area code):

Cell Phone (please include area code):

Work Phone (please include area code):

Social Security last 4 numbers (xxx xx - - - -):

Medicare #:

Part A:

Part B:

Name of Facility Resident is coming from:

Admission Date:

Address of Current Facility:

Phone Number of Current Facility:

Contact Person:

Address:

Phone Number:

 

Contact Person(s):

Person 1

Name:

Relationship:

Address:

Home Phone:

Work Phone:

Cell Phone:

 

Person 2

Name:

Relationship:

Address:

Home Phone:

Work Phone:

Cell Phone:

 

Medical Information:

Diagnosis:

Please check all applicable conditions:

Mentally Alert

Ambulatory

Confused

Needs Assistance with Dressing, Bathing, and Hygiene

Incontinent

 

Financial Information:

To process your application, the following information is needed concerning the prospective resident's finances. Please indicate the resources which are available to pay for the cost of care. The information supplied will be strictly confidential and will be used to assist you in your long term planning.

Person who will be responsible to ensure that payment is made and made in a timely manner. (The person listed must also sign at time of admission)

Name:

Relationship:

Address:

Home Phone:

Work Phone:

Cell Phone:

Has anyone been appointed Power of Attorney?

Yes No

If yes, Who?

Has anyone been appointed Durable Power of Attorney or Guardian?

Yes No

If yes, which & who?

Does the Resident have a Living Will or Advance Directives?

Yes No

If the answer to any of the above question is "Yes", please provide Solomons Rehab and Care Center with copies of the documents

Was the applicant admitted to a skilled nursing center or hospital during the last 60 days?

Yes No

If yes, provide name and telephone number:

Does the applicant have any other insurance that covers skilled nursing care?

Yes No

Has the applicant applied, or will the applicant soon be applying for Medical Assistance?

Yes No

If yes, provide Medical Assistance Number:

If the applicant has applied, what was the date:

What county:

Department of Social Service Representative:

Phone:

 

Prospective Resident's Monthly Income

Salary:

Social Security:

Pensions / Annuities:

IRA:

Interest /

Dividend Income:

Rental Income:

Other Income (specify):

Total Monthly Income:

 

Prospective Resident's Assets

Cash assets in Banks, Credit Unions, and Financial Institutions:

Institution Name:

Balance in account:

Institution Name:

Balance in account:

Institution Name:

Balance in account:

Institution Name:

Balance in account:

 

Real Estate Assets

Does Resident own a home?

Yes No

if yes, balance in account:

Does Resident own a property?

Yes No

if yes, balance in account:

Life Insurance Cash Value -

Any policy with Cash Value?

Yes No

Company Name:

if yes, approximate value:

Other assets (Automobile, Business Interests) specify:

Value:

Total Assets:

Comments / Notes:

 

Prospective Resident's Liabilities

Home Mortgage $:

Credt Card Charge Amount $:

Loans $:

Other Debts $:

Specify:

Taxes Owed $:

Total Liabilities $:

Net Worth (Total Assets - Total Liabilities) $:

 

Payment Terms and Agreement

 

If you agree to these terms and conditions, please type I agree in the field below.

 

Please click the checkbox below to verify your identity.