REDWOOD HILL ADULT FAMILY HOME Application for Residency and Emergency Information Form 27229 45 th Pl South Kent, WA 98032 Tel (253) 981-3688 / Fax (253) 981-3586 Email: info@redwoodhillafh.com www.redwoodhillafh.com All information will be held in strict confidence. Please answer all questions. I agree that this application shall become part of any subsequent agreements of admission. GENERAL INFORMATION Application Date: Admit Date: Discharge Date: Is there a need for a secure alzheimer s unit, (i.e., would resident be at risk for wandering or exit seeking)? Yes No Are you interested in a private room? Yes No Semi-private room? Yes No Name Last, First, M.I. Nickname: Gender: M F Home Present Address Street, City, State, Zip Cell Email Permission to contact using e-mail address? Yes No How many years of residence at present address? Current status: Owner Renter Living with relatives Other, please explain: Date of Birth: Age: US Citizen? Yes No Current Height: Current Weight: Allergies: Social Security #: Medicare #: Veteran #: Marital Status: Single Married Widowed Divorced Unknown Spouse Name, if applicable: Date & Place of Marriage: If spouse is deceased, please list date of death: Last regular occupation of Applicant: Last regular occupation of Spouse: Year Retired: Year Retired: Primary Language: English Spanish Other, Please specify Resident s mail to be delivered as follows: All mail to the Resident Personal mail only to the Resident with all business mail (bills) forwarded to: All mail to responsible party I agree to allow a representative of Redwood Hill Adult Family Home to open and read my mail, if my condition warrants, through my oral consent. (Initial) Release of Information: I authorize release of information to state agencies by Redwood Hill Adult Family Home for reason of admission, discharge, or public relations. Yes No CONTACT THE ADMINISTRATOR IF YOU WISH NO TO HAVE YOUR PRESENCE DISCLOSED IN THIS FACILITY. 1
Photographs: I (Resident / POA) give permission for (Resident) to have his/her picture taken for the purpose of: Identification Display Board in the AFH AFH Website Photo Album Newspaper Local AFH Association Newsletter Senior Fair Display Board Association Meetings Legislative Display Board Other, i.e., Summer BBQ/Holiday Parties MEDICAL/PROVIDER INFORMATION Primary Physician: Office Fax: I authorize Dr. to be the physician in charge of treatment. In an emergency or if the attending physician is not available to provide the services as required by Federal or State guidelines, I authorize the designated doctor on call to assume responsibility for my medical care. Specialist: Office Fax: Dentist: Office Fax: Date of Last Visit: Optometrist: Office Fax: Date of Last Visit: Is applicant coming to Redwood Hill Adult Family Home from the hospital? Yes No If yes, name of Hospital Reason for Hospitalization Hospital Discharge Planner Phone ( ) Current Medical Diagnosis: Do any of the following conditions exist? Diabetes Yes No History of stroke Yes No High blood pressure Yes No Heart surgery Yes No What special equipment is needed? Intravenous fluids Tube feeding Oxygen treatment Other List major surgeries or illnesses within the past year: 2
List any specific physical limitations: List any other necessary information about personal and/or health history: Do you smoke? Yes No Do you drink alcoholic beverages? Yes No Nurse Assessor: Hospital preference: Funeral home preference: Mortician: Personal responsible for funeral arrangements: Pharmacy Services: Medications will be procured from a local pharmacy. This facility will not be responsible for any errors that might be made by a pharmacy outside the facility in filing resident s prescriptions. The facility retains the right to obtain emergency medications, as ordered by the attending physician. Pharmacy s Name: List of prescribed medications: Name of medication Name of doctor who prescribed medication Dose Time(s) of day Form (liquid, capsule, tablet) Special instructions (such as with food ) Over-the-counter medication* Reason taken Dose Time(s) of day Form (liquid, capsule, tablet) Special Instructions (such as with food ) 3
*Over-the-counter medications could include vitamins, nutritional supplements, pain relievers, antacids, laxatives, and/or herbal remedies. Have you had previous adult family home stay(s)? Yes No If yes, when and where and state reason for leaving: Do you have a Living Will or Advance Directive? Yes No If yes, please furnish a copy of this optional form. Advance health care directives, also known as living wills, advance directives, or advance decisions, are instructions given by individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or incapacity. (source: Wikipedia) Name of Agent: Location of Document: Do you have a Durable Power of Attorney for Health Care? Yes No Required: A true and correct copy MUST be submitted with this Application. Name of Agent: Relationship: E-mail Home Cell Work FINANCIAL INFORMATION Do you have a Durable Power of Attorney for Finances? Yes No Required: A true and correct copy MUST be submitted with this Application. Name of Agent: Relationship: E-mail Home Cell Work Person responsible for receipt and payment of billing statements: Name: Address Relationship: E-mail Home Cell Work Receipt for Services I am satisfied that my returned check will act as my service receipt. Therefore, I do not require a receipt to be provided from Redwood Hill Adult Family Home unless I have requested one. Yes No Initial Please list health, supplemental, accident or long-term care insurance policies: Health Insurance: Yes No Preauthorization Required? Yes No Name of Insurance Company: Supplemental Health Insurance: Yes No Name of Insurance Company: 4
Accident Insurance: Yes No Name of Insurance Company: Long-term Care Insurance: Yes No Name of Insurance Company: Does a bank trust department manage financial affairs? Yes No If yes, please furnish information. Name of Bank: Name & Title of Contact: I have the following sources of income and/or assets, please list amount per month: Social Security Yes No $ Supplemental Social Security Income Yes No $ Pension Yes No $ Investment, stocks, bonds, annuities Yes No $ Insurance benefits or payments Yes No $ Income from renters Yes No $ Income from contracts for deed Yes No $ Other retirement income Yes No $ Savings accounts Yes No Name of Bank: $ Checking accounts Yes No Name of Bank: $ Veteran s benefits or pension Yes No $ Other Yes No $ For how long do you estimate your personal resources will be sufficient to provide for your care while a resident here? Years Resident s Personal Funds (Trust Account): We recommend that the resident keep only a minimum of cash on his/her person. Provisions are made for handling personal funds in the business office and they are readily available to the resident or responsible person as needed. Business hours are Monday through Friday 8:00 AM to 4:00 PM. Upon request of the resident or responsible party, resident funds may be deposited and withdrawn as desired from a resident trust account during stated hours. The resident or responsible party shall receive a quarterly accounting of all financial transactions in the resident trust account. A monthly accounting may be provided upon request. If these funds are over a certain limit as prescribed by law they will be maintained in a local financial institution. I do do not authorize Redwood Hill Adult Family Home to open and maintain a trust account on my behalf during my stay at this facility. I do do not authorize Redwood Hill Adult Family Home to pay out of my trust account, on my behalf, the expenditures listed below: 5
EMERGENCY CONTACTS A. Name: Relationship: E-mail Home Cell Work B. Name: Relationship: E-mail Home Cell Work C. Name: Relationship: E-mail Home Cell Work PERSONAL / SOCIAL HISTORY Please share any personal or social history information that would help Redwood Hill Adult Family Home staff better serve you. Birthplace: Father s name: Number of brother(s) and sister(s) living: Nationality: Mother s name: Number deceased: Number of Children Born, list living children below: Name: Name: Name: Other close relatives or friends: Education: Name: Name: Religion: Name of Priest or Pastor: Church or synagogue affiliation: Military service/branch: Significant experiences / achievements: Hobbies and interests: Involvement with civic or political organizations: Felony convictions? Yes No If yes, please furnish information. 6
Are you a Sex Offender? Yes No If yes, please furnish information. DISCLAIMER AND SIGNATURE The undersigned hereby makes applications for residency in Redwood Hill Adult Family Home located in Kent, Washington. The above information is true and correct to the best of my knowledge and belief. I have no objections, and hereby authorize representatives of Redwood Hill Adult Family Home to make such inquiries as they deem necessary for the purpose of verifying the statement make herein. I understand that my acceptance is based on Department of Social and Health Services regulations and my ability to pay the private monthly rate. Applicant Signature Spouse s Signature Applicant s Legal Representative s Signature Date Date Date Applicant s Legal Representative s Relationship to Applicant 7