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PHOEBE MINISTRIES
On-Line Admission Application

The information requested within this application is required to evaluate a prospective resident’s request for admission. All information contained within this form shall be held in the strictest confidence. The authorized recipient of this information is prohibited from disclosing this information after its stated need has been fulfilled.

Application for Phoebe Richland Health Care Center, Richlandtown, PA:

SECTION ONE - APPLICANT 1 - PERSONAL INFORMATION *denotes required field

1. Name*  (Last)*
 (First)*
 (MI)*
2. Street*
3. City*
4. State*, ZIP*
5. County*
6. Telephone*   
(e.g., 123-456-7890)
7. Marital Status Married
Never Married
Widowed
Divorced
Separated

8. Applicant is currently at
  Home  
  Personal Care / Asst. Living
  Other Nursing Home
  Hospital

9. Birthdate*
10. Sex Male
Female
11. SSN
12. Religious Affiliation (OPTIONAL)
13. Church / Temple (OPTIONAL)
14. Ambulance Membership / Affiliation / Preference (OPTIONAL)
15. Contact Person(s)  
Name*
(Home)*
Address*
(Work)
Relationship*
(Cell)
(Email)*
Name
(Home)
Address
(Work)
Relationship
(Cell)

16. What type of Power of Attorney do you have? Financial
Medical
Durable
None

Name
Address
Phone

17. Anticipated length of stay Short Term
Long Term
Undecided

SECTION TWO - HEALTH INSURANCE / PRESCRIPTION COVERAGE

18.

Medicare A B Medicare A Number Medicare B Number
       
HMO  
(HMO Number)		  
       
Secondary / Other Insurance (Name of Insurance) (Insurance Number)
     
Long Term Care Insurance
    (Name of Insurance)
(Insurance Number)

SECTION THREE - FINANCIAL INFORMATION

19. Do you own your home? Yes No
20. House value
21. Do you currently have a
      mortgage on your home?		 Yes No

22. Monthly Income

Pension
Social Security
Annuity
     
Other (Please list):
(Name)
(Amount)
Other (Please list):
(Name)
(Amount)
Other (Please list):
(Name)
(Amount)
     
Total monthly income from all sources:

23. Estimated total assets, excluding home

24. Have you transferred any real estate, personal property, money, stocks, bond, mortgages, or anything else of value during the last three years?

Yes

No

Name of Person Transferred to
Date of Transfer
Amount of Transfer

25. How did you hear about Phoebe Ministries?

Friend/Relative Church Resident of a Phoebe Community
Newspaper Internet Other

I understand that any misrepresentation or omission of information on this application will disqualify me from consideration of possible admission to the facility indicated and will be cause for discharge if discovered after my admission.

I certify that the information contained within this application is true and accurate to the best of my knowledge.

Note: Compliance is denoted through electronic submission.
Name of Applicant*
Name of Person Completing
Application*
Date*

 

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1925 Turner Street Allentown PA 18104 1-800-453-8814