Name Telephone. Address. Physician Birthdate Marital Status. Current Medical Conditions. Name Telephone. Address. Address

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Marian Hodge
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1 PortagePointe ELDER ADMISSION APPLICATION Name Telephone Address Physician Birthdate Marital Status Current Medical Conditions Does applicant have a Legal Guardian? Yes No Name Telephone Address Does applicant have a Durable Power of Attorney for Healthcare? Yes No Name Telephone Address Do you presently receive services from the system? Yes No Portage Home Health Portage Home Services Other Other home care providers (home health, durable medical equipment, UPCAP): Social Security Number Medicare Number Medicaid Number Veterans Claim Number Part A Part B Other Healthcare Insurance(s) Person responsible for financial arrangements Address Telephone Who should we contact about possible openings in our home? 1. Name Home or Cell Phone Address Work or Cell Phone 2. Name Home or Cell Phone Address Work or Cell Phone Signature of person completing application Relationship to applicant Date F:\PATIENT SERVICES\MANUAL - PORTAGEPOINTE\2011\ELDER ADMISSION APPLICATION 0811.DOC

2 Information About the Use or Disclosure AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION MR#: I hereby authorize the use or disclosure of my protected health information ( PHI ) as described below: Individual s Name: Previous Name: Address: (Print or type full name) Date of Birth: Day Phone No.: Evening Phone No.: Persons/organizations authorized to release the PHI: Name of Person/Organization to Release PHI Address City, State, Zip Persons/organizations authorized to receive the PHI: Name of Person/Organization to Receive PHI Address City, State, Zip Specific description of PHI to be used or disclosed (please check all that apply): Hospital Records: Date Physician Office Records: Date ED M.D. Visit Note Discharge Summary Medication List Operative Report Problem List Lab(s) Immunization Record X-ray(s) Referral Report Inpatient Record Lab(s) Other (specify) X-ray(s) Other (specify) I specifically mean this to include any information regarding HIV/AIDs, Drug or Alcohol use/abuse, Mental Health and other records in accordance with federal regulations. Please cross out any that do not apply. Specific purpose of the disclosure (please circle one): Continuing care Insurance Legal Personal Other (please state): This authorization will expire: One (1) year from the date of your signature below [indicate a date (e.g., December 31, 2004) or an event relating to the purpose of the authorization (e.g., rejection of my life insurance application ] Important Information About Your Privacy Rights I have read and understood the following statements about my privacy rights: I may revoke this authorization at any time prior to its expiration date by notifying the Director of Medical Records in writing, but the revocation will not have any effect on any actions Portage Health System took in reliance on this authorization before it received my revocation. I may request a copy of this authorization from the provider. The provider must provide me with a copy of my signed authorization. The provider may not require you to sign this authorization in order for you to receive treatment. Information that is used or disclosed pursuant to this authorization may be redisclosed by the receiving entity. Signature of Individual (or Individual s Representative) Individual s Signature: Date: If the authorization is being signed by a personal representative of the individual (such as a parent of a child under the age of 18): Personal Representative s Signature: Date: Type/Print Name of Personal Representative: C:\WP6 Documents\FORMS\Authorization for Use-Disclosure of PHI.wpd

3 PortagePointe FUNCTIONAL ASSESSMENT Name: Please put an X in all boxes that best describes you (the Elder). MOBILITY LEVELS Is able to walk: Does not walk Climbs stairs alone Does not climb stairs Uses Brace Uses Prostheses Uses Walker Uses Cane Is able to turn in bed Is able to transfer out of bed/chair: With supervision With a lift WHEELCHAIR Is able to wheel self Is pushed Care of Teeth/Mouth Is able to perform alone Has dentures Upper Lower Has no teeth Has own teeth Has a partial plate DRESSING Is able to dress self HAIR CARE Is independent TAKING A BATH - without help With supervision F:\PATIENT SERVICES\PORTAGEPOINTE\FUNCTIONAL_ASSESSMENT.1006[1][1].DOC

4 PortagePointe FUNCTIONAL ASSESSMENT Name: Please put an X in all boxes that best describes you (the Elder). TOILETING With supervision BOWEL FUNCTION Is continent COMMUNICATION Has normal speech Has impaired speech Does not speak Is able to write Language Spoken: Is hard of hearing Is incontinent Has a Hearing Aid R L Has accidents Has an ostomy Wears Depends BLADDER FUNCTION Is continent Is incontinent Has accidents Has a catheter Wears Depends VISION Is normal Is impaired Wears glasses EATING AND FEEDING Eats by him/her self Needs supervision of one Must be fed Needs encouragement Is tube fed Uses adaptive equipment THOUGHT PROCESS Is clear Is distorted Has problem with memory Is able to make decisions F:\PATIENT SERVICES\PORTAGEPOINTE\FUNCTIONAL_ASSESSMENT.1006[1][1].DOC

5 PortagePointe FUNCTIONAL ASSESSMENT Name: Please put an X in all boxes that best describes you (the Elder). Wears contacts THOUGHT PROCESS (con t) Able to answer appropriately Can follows directions Can make self understood SHOPPING Able to ask appropriate questions TRANSPORTATION LAUNDRY COOKING Signature: Date: Signature: Date: F:\PATIENT SERVICES\PORTAGEPOINTE\FUNCTIONAL_ASSESSMENT.1006[1][1].DOC

6 Elder s Name: Healthcare Provider Information Physician s Name: Physician s Address: Physician s Phone Number: Is your physician aware of your intent to move into PortagePointe? Yes No Home Health Provider Name: Address: Phone: F:\PATIENT SERVICES\PORTAGEPOINTE\HEALTHCARE_PROVIDER_INFORMATION_FORM.1006[1][1].DOC

Elder s Name: Other Information Needed Please provide us with a copy of the following information: Social Security Card Medicare Card Medicaid Card Medicare Part D Provider Card Any Other Insurance

7 Elder s Name: Other Information Needed Please provide us with a copy of the following information: Social Security Card Medicare Card Medicaid Card Medicare Part D Provider Card Any Other Insurance Cards Have you had a flu shot this year? Yes No Have you had a recent TB test? Yes No Where? What is your current living arrangement? Home With family Assisted living center Name: Other nursing home Name: F:\PATIENT SERVICES\PORTAGEPOINTE\OTHER_INFORMATION_NEEDED.1106[1][1].DOC

SKILLED NURSING & REHAB APPLICATION Name Date of Birth Age Address Street/R.R. Box No.

SKILLED NURSING & REHAB APPLICATION Date of Birth Age Street/R.R. Box No. Town State Zip Township County Marital Status M W S D Sex Birthplace Social Security Number Two (2) persons to contact in case