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ADMISSION APPLICATION

 

FOR OFFICE USE ONLY 

LASATA CARE CENTER

 

Date Received: 

Phone: 262-377-5060

 

 

Admission Date: 

Fax: 262-377-4202

 

 

 

Payment Source: 

 

 

 

 

 

Doctor at Lasata: 

Please complete every question

Unit 

Room 

Incomplete Applications will be returned

Resident Number 

 

 

 

 

 

Admitted From 

Date:  ___________________________

 

Long Term:

Short Term

Name:  _____________________________________________________________________________________________________________________

              ( Last, First, Middle)                                           (Maiden)                   (Likes to be called)

Address:  ___________________________________________________________________________________________________________________

                _________________________________________________________________________________________

Phone Number:  ________________________

Martial Status (circle one)   S     M     W     D    Sep

Date of Birth:  _________________________

Place of Birth:  _____________________________

Sex:  _______

Year First Moved to Ozaukee County:  _________________________

Prior County if less than two years residency in Ozaukee County:  ____________________________________

If applicant does not meet residency requirement of past two years or majority of adult life, please indicate name and address of relative who meets residency requirement.

Name

Relationship to Applicant

Address

Year Moved to County

Please furnish copies of all cards, front and back. 

Social Security No: 

Medicare  (Title 18) No: 

Medicaid (Title 19) No: 

Medicare Supplemental Insurance Information 

Company Name 

Address 

 

Phone Number 

Policy Number                                                                          Group Number:

To Whom Should the Billing Statement be sent? 

Name 

Relationship to Applicant:

Address 

Phone:

 

Do you speak and understand English?            German ?              Spanish?               Other ?      

Former Occupation                                              

Have you ever been a resident at Lasata Care Center before?                   , or another nursing home?       

What type of room do you prefer? Single (Private)                Double                   Either                         

Church Affiliation                                                    

Pastor                                                                  

Address of Church:

Do you have a funeral trust?

Funeral Home

Family Physician                                   

Phone No:

Address

Family Dentist                                                  

Phone No:

Address                                                                                                                                          

Pharmacy                                                         

Phone No                                                     

Persons to Notify in Case of Emergency

First Contact Name

Home Phone

Alternate Phone Number

Address

 

Relationship

Second Contact Name

Home Phone

Alternate Phone Number

Address

 

Relationship

Third Contact Name

Home Phone

Alternate Phone Number

Address

 

Relationship

FINANCIAL INFORMATION****LASATA CARE CENTER  

Assets and Monthly Income (or attach personal financial statement)  

 

Total Amount

Institution Where Kept

Monthly Income

Social Security

 

 

 

SSI Check

 

 

 

Retirement/Pension Plans

 

 

 

Stock and Bonds

 

 

 

Annuities

 

 

 

Savings

 

 

 

Checking Account

 

 

 

Other

 

 

 

Long Term Care Insurance Coverage

Terms of Policy:

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

Real Estate Owned Property Address

 

Fair Market Value

 

Mortgages or liens

 

Is the property for sale?

 

 

 

 

 

 

 

 

 

Life Insurance Company Name

 

Face Value

 

Cash Value

 

 

 

 

 

 

 

 

 

Have you sold or given away any assets or property in the past thirty six months?

If so, please provide details including what, how much, to whom and when. (attach written explanation)

NO:

YES:

GUARANTEE OF PAYMENT 

I agree to be responsible and pay for all sums due and owing Lasata Care Center upon receipt of bill.  In the event that I am entitled to benefits from Medicare and Medicaid, such benefits are assigned to Lasata Care Center for application on my bill under terms as are required by the programs.  In the event that I am entitled to benefits from my insurance policy, such benefits are assigned to Lasata Care Center for application on my bill.  I am aware that charges for room and board, nursing care, drugs and nursing supplies, are made monthly and are for services received in the prior month.  I agree to be responsible and pay for all sums not covered by these assignments. 

If accepted for admission by Lasata Care Center, I agree not to make any inappropriate disposition (divestment) of assets, which would impair my ability to pay for my care. 

I certify that the statements contained in this application are true to the best of my knowledge.  I understand that any false statements or willful misrepresentation shall be cause for rejection of my application and may be grounds for dismissal from Lasata Care Center, if admitted. 

This is an application for voluntary admission and can legally be signed by applicant or court appointed legal guardian or ACTIVATED Power of Attorney for Health Care only.   

If signed by a legal guardian, documents must accompany application.  OR applications signed by a Power of Attorney for Health Care will only be accepted with accompanying doctor’s statements of incapacity. 

 

__________________________________________ ___________________________________________
Applicant   OR   Court appointed Legal Guardian OR Witness
Agent in an activated Power of Attorney for Healthcare

Do you wish to be on the active list ________________  or inactive list? _______________  
If left blank, we will assume inactive placement.

 

Additional medical forms will be provided upon notification of the availability of a room, which must be submitted just prior to your admission.