D Mental Health Services D Private Duty/Other

Transcription

1 Application for Admission Rockingham County Rehabilitation & Nursing Center Applicant's Primary : Other (if living with someone): Hospital/Rehab Hospital being referred by: No./Social Hospital: Perso~ l lnforma,tk>n Regarding Applicant: Male U Female U OB: Marital Status: S M W Sep. iv. Primary Physician: Specialist: Primary Language: ( and Tel. No.) English: Other: Any special needs required: Contact Person Regarding this Application: : Relationship: 2nd Contact: : Tel. No.: Living Arrangements: Lives alone or Other: Prior Hospitalizations/In-home Services: Rehabilitation Services Home Health Services VNA Services Mental Health Services Private uty/other Insurance Information for Nursing Home Stay: Private Funds (advance ga:rment reguired) Medicaid No. Medicare No. Medicare Replacement Carrier: Social Security No. VA No. Supplemental Insurance: Ins. I.. No.: Name/ Supplemental Insurance: Relationship: Tel. No.: Responsible Person/Legal Guardian/POA: Legal Guardian urable POA (Health) urable POA (Finances) : Relationship: Tel. No.: Is POA for health activated? Yes No (Provide copies of above documents) Enrolled in Medicare "" Prescription rug Program: Yes No (Provide copies of all cards; front and back) Monthly Income Source(s)/Assets: Social Security check $ Pension check $ Name/ of Pension Company: - Advanced irectives in Place: Living Will o Not Resuscitate o Not Hospitalize Organ onor Feeding Restrictions Medication/Treatment Restrictions (Explain): Assets: Value: Real Estate: $ Savings Account: $ Checking Account: $ Retirement Account: $ Stocks/Bonds: $ IIWC: $ Have you transferred/gifted assets within last 5 yrs? Yes No (Copies of most recent statements required)

2 2 iagnoses (list all): Medications (list all): Comments/pertinent information explaining whv this person needs to be placed in a nursing home: COMMUNICATION I authorize the Rockingham County Rehabilitation and Nursing Center to communicate via and/or fax with the following individuals Na me/relationship I acknowledge that and fax communications are not secure, and that confidential information sent via or fax may be intercepted and used by unauthorized persons. I accept these conditions and waive any violation that might arise from an unauthorized interception and/or use of or fax. I give authorization to leave a detailed message on voice mail Yes No Signature of Person Completing Application ate of Application 1/16

3 RESIENT AVOCACY LIST Pg 1 Bureau of Elderly and Adult Servrces T Access Relay Adult Protection Adult Protection Toll Free Mailing (603) (800) (603) (603) (800) State Committee on Aging Bureau of Bderty & Adult SelVices ivision of Community Based Care Services NH eparbnent of Health and Human Services T Access Relay Mailing The.Social Security Administration Medicaid Fraud Local Nafl TTY Mailing T Access Mailing (603) (800) (603) Office of the Commissioner NH epartment of Health and Human SelVices (888) (800) (603) The Social SeaJrity Administration 80 aniel Street Portsmouth, NH (603) Medicaid Fraud 33 Capitol Street

4 RESIENT AVOCACY LIST Pg 2 epartment of Health & Human Services T Access Relay (603) (800) (603) Mailing epartment of Health and Human Services Seacoast istrict Office 50 International rive Portsmouth, NH NH Licensing and Certification Services T Access Relay Mailing Health Facilities Administration T Access Relay (Licensing) (Certification) CUA Home Health Hotline MOS/OASIS MOS/OASIS Fax Mailing (603) (800) , ext (603) Licensing & Certification Services Office of Operations Support NH epartment of Health & Human Services 121 South Fruit Street (603) (800) , ext (603) (603) (603) (800) (603) (603) Bureau of Health Facilities Administration Office of Operations Support NH epartment of Health & Human Services

5 RESIENT AVOCACY LIST 1sab1ll 1es Rights Center Pg 3 Service link VfITY Mailing (603) (800) (603) ' isabilities Rights Center 64 N Main Street Ste2 Fl 3 (603) Mailing Service link 127 Parrott Avenue Portsmouth, NH 03801