APPLICATION FOR ADMISSION

APPLICANT NAME ____________________________________________________________

LAST FIRST MI

HOME ADDRESS ______________________________________________________________

STREET/APT. NO.

_____________________________________________________________

CITY STATE ZIP CODE

COUNTY OF RESIDENCE______________________________________

SEX _____M _____F DATE OF BIRTH _____________ BIRTH PLACE __________

MO/DAY/YEAR

MARITAL STATUS ( ) SINGLE,NEVER MARRIED ( ) MARRIED ( ) SEPARATED ( ) DIVORCED ( ) WIDOWED

NAME OF SPOUSE ______________________________

RELIGION ____________ OCCUPATION BEFORE RETIREMENT ___________________

PRIMARY LANGUAGE __________________________

SOCIAL SECURITY NUMBER ________________ MEDICARE NUMBER _____________

(PLEASE PROVIDE COPY) (PLEASE PROVIDE COPY)

MEDICAID NO. ___________________ PROGRAM (i.e. CCPED, etc.) ________________

(PLEASE PROVIDE COPY)

HAS AN APPLICATION BEEN SUBMITTED FOR MEDICAID _____ YES _____NO

IF YES, WHEN ___________ WHAT COUNTY______________

CASEWORKER ________________________________

VETERAN STATUS ___________ BRANCH __________

ADDITIONAL HEALTH INSURANCE _____YES _____NO

IF YES: COMPANY NAME _______________________________________________

ADDRESS ______________________________________________________

______________________________________________________

ID NUMBER ___________________________________________________

(PLEASE PROVIDE A COPY OF THE CARD AND THE BILL)

CURRENT LIVING ARRANGEMENTS _____ HOME _____ HOSPITAL (NAME) _____________

_____ NURSING HOME (NAME) ________________

MEDICAL DIAGNOSIS/NEED FOR NURSING HOME CARE (BRIEF DESCRIPTION):

_____________________________________________________________________________

_____________________________________________________________________________

NAME OF PHYSICIAN(S) CURRENTLY PROVIDING YOUR CARE:

______________________________________________________________________________

HOSPITAL PREFERENCE:

_____ SHORE MEMORIAL _____ ACMC - MAINLAND

_____ ACMC - CITY _____ OTHER-SPECIFY ______________

FUNERAL HOME ____________________________ PHONE NO. __________________

ADDRESS _____________________________________________________________

_____________________________________________________________

DOES APPLICANT HAVE AN ADVANCE DIRECTIVE/LIVING WILL?_____YES_____NO

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INCOME: SOCIAL SECURITY _____ YES _____ NO MONTHLY AMOUNT __________

PENSION _____ YES _____ NO MONTHLY AMOUNT __________

OTHER INCOME* _____ YES _____ NO MONTHLY AMOUNT __________

*IF YES TO OTHER INCOME, IDENTIFY SOURCE: _______________________________________________________

( PLEASE PROVIDE VERIFICATION OF INCOME(S))

RESOURCES, PLEASE LIST VALUE:

( ) CASH ON HAND _______________

( ) SAVINGS AND/OR CHECKING ACCOUNTS _______________

( ) CERTIFICATES OF DEPOSIT _______________

( ) STOCKS/BONDS/INVESTMENTS _______________

( ) OWNERSHIP OF ANY REAL PROPERTY _______________

PLEASE PROVIDE VERIFICATIONS OF ALL ACCOUNTS (i.e., BANK STATEMENTS, ACCOUNT

STATEMENTS, DEED, MORTGAGES HELD, etc.)

PRIMARY PERSON TO BE CONTACTED IN AN EMERGENCY:

NAME _______________________________________ RELATIONSHIP _______________

ADDRESS ____________________________________________________________________

TELEPHONE NO. (H) _______________ (W) _______________

SECONDARY CONTACT PERSONS:

NAME _______________________________________ RELATIONSHIP _______________

ADDRESS ____________________________________________________________________

TELEPHONE NO. (H) _______________ (W) _______________

NAME _______________________________________ RELATIONSHIP _______________

ADDRESS ____________________________________________________________________

TELEPHONE NO. (H) _______________ (W) _______________

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IF ANY INFORMATION THAT IS LISTED ON THE APPLICATION SHOULD CHANGE OR IF WE CAN HELP WITH ANY QUESTIONS YOU MAY HAVE, PLEASE CONTACT THE ADMISSIONS OFFICE AT (609) 645-5955, extension 4556, MONDAY THROUGH FRIDAY, 8:30am - 4:30pm.

By signing this application I hereby authorize Meadowview Nursing Home to request medical information concerning the person applying for admission.

_________________________________________ __________________

SIGNATURE OF APPLICANT OR REPRESENTATIVE AND DATE

PLEASE RETURN COMPLETED APPLICATION TO:

ADMISSIONS OFFICE

235 DOLPHIN AVENUE

NORTHFIELD, NJ 08225

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FOR OFFICE USE ONLY

______________________________________ BY ________________________________

DATE RECEIVED BY MEADOWVIEW NURSING HOME