Skilled Nursing Application by Matt Elliott | Dec 12, 2024 M Skilled Nursing Application Step 1 of 14 - Primary Application Contact 0% Primary ContactPerson completing this form will be the primary contact for any questions regarding the resident application.Primary Contact Name(Required) First Last Primary Contact Phone(Required)Primary Contact Email(Required) Resident InformationResident Full Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Resident Phone(Required)Resident Current Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Resident InformationSocial Security Number(Required)Date of Birth(Required) MM slash DD slash YYYY Place of Birth(Required)Profession/Career(Required)Marital Status(Required)SingleMarriedSeparatedDivorcedWidowName of the Spouse Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last If Deceased, Date of Death MM slash DD slash YYYY Person Responsible for Funeral ArrangementsName(Required) First Last Phone(Required)Funeral Director's Name First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Burial Arrangement Yes No Military Experience:Military Experience Yes No From MM slash DD slash YYYY To MM slash DD slash YYYY BranchWar World War 2 Korean War Vietnam War National Guard Other Other Church AffiliationName of ChurchName of Minister First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Medical InformationHealth InsuranceInsurance NumberPhoneLong-Term Care Insurance CompanyPolicy NumberElimination Period (# of days waiting period)Daily Payment (Per Diem)Medicare Number Physician Name ( Must choose a Boone doctor): First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Dentist Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Optometrist Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Are you currently using VA medications? Yes No Please list all medications taken at home including supplements.Westhaven Community uses Medical Associates as its pharmacy.Medications Taken at Home (including over the counter medications)MedicationDoseHow Often Add Remove Social SecurityAmountComments/ExplanationsRailroad RetirementAmountComments/ExplanationsVeterans PensionAmountComments/ExplanationsIPERSAmountComments/ExplanationsAnnuitiesAmountComments/ExplanationsOther IncomeAmountComments/ExplanationsValue of Home/FarmAmountComments/ExplanationsSavings and/or investmentsAmountComments/ExplanationsTrust FundAmountComments/ExplanationsTotal AssetsAmountComments/Explanations In Case of Emergency Please NotifyContact Details Name Relationship Phone Actions Edit Delete There are no Contacts. Add Contact Maximum number of contacts reached. Documents Upload Drop files here or Select files Max. file size: 128 MB, Max. files: 10. The following documents are needed in order to complete the application process. You can either upload them now online or bring them with you in person. Document List: Photo I.D., Insurance Cards, POA Paperwork, and Living Will Please Note: ALL SECTIONS of this application form must be filled out completely and it must be signed prior to Westhaven Community consideration for admission.Consent(Required) I certify that to my knowledge all information included in this application is true and accurate.Date MM slash DD slash YYYY Signature
