ADMISSION APPLICATION

Date	7/5/2008
First Name
Middle Name
Last Name
Street Address
City
State
Zip
Telephone Number
Primary Occupation
Birthdate
Place of Birth
Marital Status	Single Married Widow Divorced

CONTACT INFORMATION

1st Contact
Name
Address
City
State
Zip
Relationship
Home Phone
Work Phone
Cell Phone

2nd Contact
Name
Address
City
State
Zip
Relationship
Home Phone
Work Phone
Cell Phone

3rd Contact
Name
Address
City
State
Zip
Relationship
Home Phone
Work Phone
Cell Phone

LOCAL PROVIDERS

Physician		Pharmacy
Dentist		Eye Doctor
Religion		Funeral Home
Church		Funeral Home City/State
Church City/State		Funeral Home Telephone Number
Hospital Preferance
Where hospitalized in past 60 days
Dates

FINANCIAL INFORMATION

Medicare #		SSN
Medical Assistance #
Hospital Insurance
Ins Policy #
Ins Group #

PLEASE INDICATE IF YOU HAVE A LEGAL DOCUMENT FOR THE FOLLOWING:
ADVANCE DIRECTIVE	Yes No
CONSERVATOR	Yes No
GUARDIAN	Yes No
POWER OF ATTORNEY - FINANCIAL	Yes No
POWER OF ATTORNEY - MEDICAL	Yes No
MISCELLANEOUS RESIDENT INFORMATION
I receive Meals On Wheels	Yes No
I am receiving Home Care Services	Yes No
If so, what agency?
I have been hospitalized in the past 30 days?	Yes No
If yes, answer below Hospital Date(s)
I have been in a Nursing Home previously?	Yes No
If yes, answer below Nursing Home Date(s)
I am currently a smoker	Yes No
Vaccinations: Note when last received. If unknown, please contact the individual's physician.
Influenza: Pneumovac:
I have been convicted of a felony.	Yes No
I have been convicted of any crime that I am required to disclose to this facility.	Yes No
If so, what?
I wish to have my clothing labeled.	Yes No
If not, the clothing will need to be laundered outside of the facility. Laundry staff have no way of knowing who the items belong to.
ASSESSMENT OF CURRENT CARE NEEDS
Please check the personal care that you need assistance with.
Bed Mobility Transfering from one position to another Eating Toileting Walking Bathing
Circumstances and Needs: Why do you think placement in the nursing home is necessary?
The Department of Human Services conducts Pre-Admission Screenings on all nursing home applicants. If this screening has not been completed for the applicant, it will need to be done prior to admission. The County in which you reside is responsible for completing this screening. The Knute Nelson operates on a monthly payment plan. The Facility provides room, board, and all professional services of a skilled nursing facility as required by State and Federal regulations. Rates may be raised or lowered as living costs go up or down and/or the level of care changes. The applicant assumes responsibility for other expenditures such as physician, medications, clothing and other personal expenses. The Facility reserves the right to assign or reassign resident rooms at its discretion. It is agreed that when the Facility is no longer able to provide an appropriate level of care, we will arrange for a transfer. Knute Nelson is a smoke-free facility.
Accept Conditions Stated Above