Residency Application Please enable JavaScript in your browser to complete this form.Name of Applicant *FirstLastAddress *City *State *Zip *Telephone # *ReligionChurchDate of Birth *Place of Birth *State *Social Security Number *Marital Status *SingleMarriedWidowedMedicare #Effective DateMedicaid #Effective DateCoinsurance Policy Co. & NoEffective DateFuneral HomePrepaidYesNoName of Person Completing this Form *FirstLastEmail Address of Person Completing this Form *Relationship to ResidentTelephone #AddressCityStateZipHow did you hear about the Anderson?NewspaperSocial WorkerOther Nursing FacilityBrochurePhysicianOtherFriendHospitalHave you visited Other Nursing Facilities?YesNoIf yes, which ones?Medical and Personal DataDiagnosesResident’s Current PhysicianTelephone #Mentally Alert *YesNoBed-Ridden *YesNoRequires Help with Feeding *YesNoIncontinent *YesNoChair-Ridden *YesNoEats Independently *YesNoContinent *YesNoWalks with Assistance *YesNoConfused *YesNoAmbulatory *YesNoForgetful *YesNoRequires Bed Rails *YesNoRequires Special Diet *YesNoCovid 19 Vaccine status *Fully VaccinatedUnvaccinatedPartially vaccinatedCovid 19 Vaccine Booster *BoostedWould like boosterAdmission Date DesiredResident Now Residing atReason for seeking admissionName *FirstLastI give permission for my (applicant’s) doctor/hospital to release Medical InformationThe names(s) of the person(s) who will be financially responsible for the cost of the care (the “Guarantor”) Telephone No:AddressCityStateZipHas a Trust Account been established? *YesNoIf yes, please detailHas a Durable Power of Attorney been appointed for financial affairs?YesNoIf yes, please DetailHas a Legal Guardian been appointed?YesNoIf yes, please detailHas a Living Will been executed?YesNoIf yes, please detailHas a Durable Medical Power of Attorney been appointed? YesNoIf yes, please detailFinancial DataTo process your application, the following information is needed. The information supplied is confidential and allows us to assist you in your long term financial planning. Your cooperation is appreciated in order to expedite the admission.Monthly IncomeSalary *Monthly IncomeSocial Security *Monthly IncomePensions/Annuities *Monthly IncomeIRAMonthly IncomeInterest/DividendMonthly IncomeRental Incomeinvestments/OthersAssetsCashCash (please list bank names and account #’s)Account #ValueSecurities (stocks bonds)DescriptionAccount #ValueReal Estate (description and location): (Example: 3 bedroom house; Jones St., Anyplace OH 99999)Account #Value Life Insurance NameCash value of Life Insurance Vested Pension Benefits DescriptionSubmit
