KINKORA PYTHIAN HOME CORPORATION 25 COVE ROAD DUNCANNON, PA (717) ADMISSION APPLICATION FOR: APPLICANT INFORMATION

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1 KINKORA PYTHIAN HOME CORPORATION 25 COVE ROAD DUNCANNON, PA (717) ADMISSION APPLICATION FOR: NURSING CARE: Private Room Semi-Private Room PERSONAL CARE: Private Room Semi-Private Room DESIRED ADMISSION DATE: APPLICANT INFORMATION APPLICANT S NAME: ADDRESS: SOCIAL SECURITY NUMBER: DATE OF BIRTH SEX: AGE: MARITAL STATUS: NAME OF SPOUSE (If Applicable) ADDRESS: TELEPHONE NUMBER: PLEASE LIST BELOW, EACH LIVING CHILD, BEGINNING WITH THE ELDEST: (If none, please list nearest relatives and friends) NAME: RELATIONSHIP: ADDRESS: TELEPHONE #: NAME: RELATIONSHIP: ADDRESS: TELEPHONE #:

2 NAME: RELATIONSHIP: ADDRESS: TELEPHONE #: - PLEASE INDICATE IF APPLICABLE: Durable Power of Attorney Financial Power of Attorney Name Address Financial Trust Officer Guardian Telephone # NAME AND TELEPHONE NUMBERS OF THREE PERSONS TO BE CONTACTED IN THE EVENT OF AN EMERGENCY: NAME HOME PHONE WORK PHONE Physician s Name Telephone # Address Is applicant currently in the hospital? If yes, Name and Address of hospital YES NO Floor/Unit # Telephone # Hospital Preference (if needed to be admitted): Church Name Telephone # Pastor s Name Telephone # Have Funeral Arrangements been made? YES NO Funeral Home s Name Telephone # Address

3 FINANCIAL INFORMATION Name of the Resident : Name of the Responsible Person (optional): Telephone No.: Work No.: Other No.: Has a trust fund been established for the Resident? Yes No Has a Power of Attorney been conferred on the person(s) to be financially responsible, or on the person(s) who will act on behalf of the resident. ( Responsible Party )? Yes No If yes, please provide a copy. Has a legal guardian been appointed by a court? Yes No If yes, please provide a copy. Has a burial trust been established? Yes No If yes, with whom? If no, who is the preferred funeral service for the Resident family? ASSETS: RESIDENT Cash Checking Savings Money-Market Certificates of Deposit _ Securities (Stocks/Bonds) _ Trust $ Annuities (if not yet paying monthly) IRA $ MONTHLY INCOME RESIDENT Salary $~ Social Security $~ Pensions/Annuities (if not above) $ IRA (if not above) $ Interest/Dividend Income $ Rental Income Trust $ Investments/Other $ Long-Term Care Insurance $ REAL ESTATE (description/location) Property: Name on Deed/Title

4 Property: Name on Deed/Title OTHER ASSETS Cash Value Life Insurance Vested Pension Benefits Business Interests Automobiles Other TOTAL ASSETS: LIABILITIES RESIDENT Home Mortgage Credit Cards/Charge Accounts Loans $ Other Debts $ Taxes Owed $ Total Liabilities: $ NET WORTH: (assets liabilities) PLEASE SIGN BELOW: I hereby warrant and represent that the information provided is accurate and complete. I understand that Kinkora Pythian Home will rely upon the accuracy and completeness of the above financial information in making an admission decision. I also understand that if any of the information is not accurate or not complete, the Facility will have detrimentally relied upon the above financial information and will suffer financial loss and harm. The assets listed are in fact available to the resident to pay for the Resident s care. Resident s or Responsible Party s Signature Guarantor s Signature Reviewed by: Admission s director Signature Administrator s Signature

5 INSURANCE INFORMATION Are you enrolled in Medicare? YES NO Medicare # Part B YES NO Do you have Blue Cross/Blue Shield 65? YES NO Plan # If Individual Coverage: Plan A B C H (please circle one) Do you belong to an HEALTH MAINTENANCE ORGANIZATION, PREFERRED PROVIDER ORGANIZATION? YES NO If YES - Name of Company: Plan # Do you have any other Health Insurance Coverage: YES NO If YES Name of Company: Plan # Do you have Long Term Care Insurance Coverage? YES NO Are you eligible for or receiving Medical Assistance? YES NO If YES Recipient # Have you sold, transferred, or given away a home, land or personal property (including cash) in the past 36 months? YES NO MEDICAL INFORMATION Reason(s) for desiring admission: Please indicate in full detail any illness, physical limitations or recent operations: Current Medications: Please list any Allergies: Please list any Medical Equipment the applicant may be currently using:

6 Does the Applicant have a History of Mental Illness: YES NO If YES, please explain: Is the Applicant receiving any Home Health or Rehabilitative Services? YES NO If YES, please explain: Does the Applicant Smoke? YES NO How Often Does the Applicant use Alcohol? YES NO How Much Has the Applicant ever required treatment relating to Alcohol or Drug Addiction? YES NO If YES, please explain: Please list any special diet requirements, food likes, dislikes and or allergies:

7 PLEASE CHECK AT LEAST ONE OF ALL THE FOLLOWING CATEGORIES: AMBULATION: Fully Ambulatory With 1 person assisting With 2 persons assisting Wheelchair Walker/Cane Bed HEARING: Good Impaired Deaf Hearing Aid VISION: Good Impaired Blind Glasses DENTAL: Has own Teeth Has Dentures Upper Lower PROSTHESIS: Please Specify V OXYGEN: Required Always Required at Times Not Required SPEECH: Can be Understood Hard to Understand DECUBITUS: Drainage Dressings WI{ERE? BOWELS: Continent Occasional Incontinence Incontinent Ostomy (please specify) BLADDER: Continent Occasional Incontinence Incontinent Catheter BATHING: Independent With Assistance Tub Shower DRESSING: Independent With Assistance Total Care GROOMING: Independent With Assistance Total Care FEEDING: Independent With Assistance Nasal/Gastro Tube DIABETIC: Yes No Please Explain THERAPIES: Physical Occupational Speech (Please indicate if applicant has or is currently receiving any of the above therapies) MENTAL STATUS: Oriented Confused at Times Always Confused ALERT: Aware of Surroundings Wanders V Noisy Combative SLEEP HABITS: Full Night Intervals Walks in Sleep DECISION MAKING: Independent Needs Assistance Unable CONVERSATIONAL: Talkative Normal Quiet EMOTIONAL: Positive Attitude Negative Attitude Withdrawn Confident Fearful Irritable Depressed Happy Pleasant Realistic Imagines Things Easy Going Defensive Good Memory Forgets I understand that Kinkora Pythian Home Corporation retains the right to accept or reject any application consistent with the law. I certify that all of the information submitted on this application is true and correct, and I understand the submission of False information may constitute grounds for rejection of this application or my discharge after admission. Signature of Applicant or Responsible Party