APPLICATION FOR ADMISSION & FINANCIAL PROFILE

DIRECTIONS: Please complete and sign. You may submit the application online, or mail, fax or hand deliver it to Potomac Valley Nursing & Wellness Center (PVNWC).
Desired Admission Date:
Room Desired: Private Semi-private Quad
Name of Prospective Resident:       Date of Birth:
Marital Status:       Sex: Male Female
 

MEDICARE INFORMATION
Medicare: Yes   No   Part A / Hospital   Part B / Medical
Medicare Plus Choice: Yes   No
Insurer:       Identification Number:
Has the prospective resident ever received skilled care in a nursing facility? Yes   No
Name of Previous Facility:        Phone #:
Dates of Skilled Care:        To:
 

OTHER HEALTH INSURANCE


Insurance Company Name:        Policy #:
Is this a Medicare Supplemental / Medigap Policy? Yes   No
Long Term Care insurance? Yes   No
If Yes, Fill Out:  
Insurance Company Name:        Policy#:
Medicaid: Yes   No   Long Term Care   Community   HMO
Life Insurance: Term     
Whole Life Face Value:
Cash Value:
Insurer:        Policy #:
Other Insurance:        Policy #:



LEGAL REPRESENTATIVE

Representative Name:  
Relationship to Prospective Resident: 
Power of Attorney: Person   Financial
Guardian: Person   Property
Address:


      
Home Phone #:
Work Phone #:   ext:
Cell Phone #:
Email Address:
Perspective Resident Admitted From: Home Hospital Nursing Home   
Other:

Signature of Resident:		  
Title:
Date:
Print Name:
   

FINANCIAL PROFILE

In order to establish that a resident has adequate financial resources for payment of services, please complete the following:

MONTHLY INCOME
Social Security: $
Retirement / Pension Source:
            		$
Rental Income: Address of Property:
             

$
Other: Source:
             		$
   
RESIDENTIAL PROPERTY (IF RESIDENT OWNS):
Title To:

Value (approx): 		 
Address of Property:                

$
Mortgage (approx):  
  Company:
         		$
  Phone:
  
Other Property Value (approx):    
Address of Property:                
$
   
ASSETS (CURRENT BALANCE OF):
Savings Account(s): Bank:
         		$
  Account #:
  Bank:
         		$
  Account #:
Checking Account(s): Bank:
         		$
  Account #:
  Bank:
         		$
  Account #:
Stocks / Bonds: $
IRA / 401 K: $
C.D.'s    Maturity Dates:
      		$
Other:    Source:
                  		$
Total Assests: $
   
LIABILITIES (medical bills, credit cards, charge accounts, loans, etc.)
Total Liabilities: $
Specific Liabilities:   
    
    
   
I hereby attest that the above financial information is accurate and assets are available to the resident to pay for services received at Potomac Valley Nursing & Wellness Center. It is understood that Potomac Valley Nursing & Wellness Center relies on the accurate and completeness of the information furnished in order to make an admission decision.
Signature of Resident:        Date:
Print Name: