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Name:________________________________________________________________ Current Address:_______________________________ Telephone: ( )__________ City:_____________________________ State:__________ Zip Code:____________ Social Security Number: - - Medicaid No. (Title XIX) _________________________ Medicare No. _________________________ Birth Date:__________________ Birth Place:_______________________________ Are you a Veteran? __________ Is your spouse a Veteran? __________ Married Status: __ Single __ Married __ Widowed __ Divorced Name of spouse:______________________ Date of Marriage:__________________ If spouse is deceased give date of death:____________________ Applicant's previous occupation:______________________ Year retired:___________ Spouse's occupation:__________________________ Number of children born:_____________ *List living children below: (Name) (Complete Address, Including ZIP Code) (Phone No.) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Were you a resident in another retirement/nursing home in the past 5 years?_______ Religious Preference *This question is optional Church Membership:___________________________________________________ (Name of Church) (Complete Address) (Phone) If you do not have church membership, do you have a religious preference:______________ If yes, what is your preference?___________________________________ Do you wish for your minister to be notified for your admission? __ YES __ NO Minister's name:______________________________________________________ Financial coverage: __ Private __ Title XIX __ Nursing Home Insurance Nursing Home or Health Insurance Policies, other than Medicare (copy of card needed):
__________________________________________________________________ (Name) (Complete Address, Including ZIP Code) (Phone No.) Responsible Person's Title: __ Social Security Payee __ Power of Attorney (POA) __ Conservator __ Other To whom should statements, business mail, etc. be sent? __ Resident __ Other
How long do you estimate your personal resources will be sufficient to provide for your care and keep while a resident at St. Luke Lutheran Nursing Home?______________ Who is to be notified in case of an emergency? List at least two in the order they are to be notified: (Name) (Complete Address, Including ZIP Code) (Phone No.) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List family members' email addresses for resident's use in the computer lab: ___________________________________________________ ___________________________________________________ Check which documents you currently have: (Please provide copies) __ Living Will __ Guardianship __ Durable Power of Attorney for Health Care Funeral Home Preference: __________________________________________________________________ (Name) (Complete Address, Including ZIP Code) (Phone No.) Do you have a prepaid funeral plan? __ Yes __ No Do you have a burial plot? __ Yes __ No Location:______________________________________________________________ Do you have a will? __ Yes __ No Who holds the will?_____________________________________________________________ Name and address of Executor: __________________________________________________________________ (Name) (Complete Address, Including ZIP Code) (Phone No.) Pharmacy- select one of the following __ White Drug __ Medicap __ Hy-Vee Physicial (required): __________________________________________________________________ (Name) (Complete Address, Including ZIP Code) (Phone No.) Dentist (required): __________________________________________________________________ (Name) (Complete Address, Including ZIP Code) (Phone No.) Optometrist/Ophthalmologist (optional): __________________________________________________________________ (Name) (Complete Address, Including ZIP Code) (Phone No.) Audiologist (optional): __________________________________________________________________ (Name) (Complete Address, Including ZIP Code) (Phone No.) Podiatrist (optional): __________________________________________________________________ (Name) (Complete Address, Including ZIP Code) (Phone No.) Medical Supplier preference: __ Lincare __ American HomePatient __ Other If other, give name and address:_______________________________________________________
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