Memory Care Application | Bethany Retirement Living

MEMORY CARE

APPLICATION FOR ADMISSION

Step 1 of 4

25%

Company

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Sex(Required)

Female

Male

Last 4 Digits of SSN(Required)

Placement Needed(Required)

Immediate

Within 6 Months

Unknown

Anticipated Stay(Required)

Short Term

Long Term

Unknown

Facility Preference

42nd St Campus

University Campus

Memory Care Unit University Campus

Room Preference

Private (Additional Charge)

Double

First Available

Civil Status(Required)

Name of Spouse

Applicant's Present Address(Required)

Street Address City State ZIP Code

Applicant's Present Phone Number(Required)

Applicant's Prior Occupation(Required)

Hometown

FINANCIAL STATEMENTS TO BE MAILED TO

Name(Required)

First Last

Phone Number(Required)

Mailing Address(Required)

Street Address City State ZIP Code

MEDICARE

Choose One

Part A

Part B

Part A and Part B

Medicare Number

Note: Copy of Medicare card needed upon admission.

OTHER INSURANCE

Primary

Policy #

Secondary

Policy #

PRESCRIPTION DRUG COVERAGE

Name

ID #

COUNTY ASSISTANCE

Do you receive any county assistance/Medicaid?(Required)

Yes

County #

No, but please provide any information regarding application:

SSI

Do you receive any SSI or SSDI (supplemental / disability) income?(Required)

Yes

VA

Is the applicant a Veteran?(Required)

Yes

If yes, contact the VA to determine eligibility for nursing home benefits

Does the applicant receive any VA benefits?(Required)

Yes

Is the applicant the spouse of a Veteran?(Required)

Yes

MEDICAL INFORMATION

Physician(Required)

Clinic(Required)

HOSPITAL PREFERENCE(Required)

Sanford

Essentia

VA (If VA, will need to be co-managed, choose 2nd option)

Other

Pharmacy Preference(Required)

White Drug at Bethany on 42nd

Medical Pharmacy

Previous Pharmacy

*Must use a 24 hour pharmacy

Pharmacy Information(Required)

Name

City

Phone #

ADVANCED DIRECTIVES

Check applicable boxes, provide copies of applicable paperwork upon admission.

Power of Attorney (POA)

Durable Power of Attorney (DPOA)

Power of Attorney for Healthcare

Guardian

Living Will

Advanced Directives

Name of DPOA/POA/Guardian

First Last

EMERGENCY CONTACTS

EMERGENCY AND FAMILY/REPRESENTATIVE NUMBERS AND ADDRESSES(Required)

Name

Address

Relationship

Phone

APPLICANT INFORMATION

Reason applicant needs skilled care:(Required)

Dementia/Memory Care

Physical Condition

Referral Source

Physician

Social Worker

Family/Friend

Other

Applicant's feelings regarding placement:(Required)

Has applicant been a resident in another nursing home?(Required)

Yes

Where?(Required)

Dates(Required)

Has applicant received prior home health services?(Required)

Yes

Agency(Required)

Dates(Required)

Mental Status(Required)

Alert

Confused

Forgetful

Depressed

Irritable

Check all applicable boxes.

Special Needs(Required)

Wanders Away

Emotional Issues

Behavioral Issues

Incontinence Issues

Terminal Care

Skin Concerns

Dialysis

Chemotherapy

Radiation

History of Falls

Bariatric Equipment

Other

Check all applicable boxes.

Hobbies/Interests(Required)

Past or Present

Highest Level of Education Completed

SPIRITUAL- Church OR Affiliation

Name

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code Country

FUNERAL HOME PREFERENCE

Name(Required)

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

ABOUT APPLICANT

Special Diet

Assistance Needed With

Check all applicable boxes.

Walking

Eating

Toileting

Bathing/Grooming

Describe medical condition(s) contributing to need for care:(Required)

PERSON COMPLETING APPLICATION

Phone # of person to contact re: application and/or openings:

Name(Required)

First Last

Phone(Required)

Home or Cell

Phone

Work

May we contact you at work?

Yes

Address of Person Completing Application(Required)

Street Address City State ZIP Code

Applicant Signature(Required)

Your Name
Your Name
Your Name

Responsible Party Signature

Your Name
Your Name
Your Name

Bethany On University

201 University Drive South

Bethany On 42nd

4255 30th Avenue South

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