The Baird Nursing Home Rochester Irondquoit Greece NY

Application for Admission

Applicant Name:

Sex:
Male
Female
Phone Number:

Date of Birth:

Marital Status:
Single
Married
Divorced
Widowed
Spouse's Name:

Address:

Street:

City:

State:

Zip Code:

County:

Primary Care Physician:

Reason for Application for Admission:
Short-term inpatient rehabilitation with subsequent discharge at home
Long-term custodial care

Location of Applicant:

	Home
	Other Residential Facility: Date of Admission
	Hospital: Attending Physician/Surgeon: Date of Adminssion/Surgery:

Responsible Parties
Will applicant act as his/her own Responsible Party/Guarantor? Yes No

Emergency Contact: Oversees applicant's personal needs:

Name:

Relationship:

Home Phone:

Work Phone:

Cell Phone:

Email:

Address:

Street:

City:

State:

Zip Code:

Guarantor: Oversees applicant's personal financial obligations:

Name:

Relationship:

Home Phone:

Work Phone:

Cell Phone:

Email:

Address:

Street:

City:

State:

Zip Code:

Conserver/Guardian?	Yes No
Durable Power of Attorney?	Yes No

How will applicant's care at The Baird be paid?:
Medicare and/or Medical insurance
Medicaid
Private Resources

Insurance Coverage:

Medicare Number:

Medical Insurance Carrier:

ID#:

Group ID#:

Long-Term Care Insurance: Yes No
If Yes, Company:
Does applicant receive Supplemental Security Income (SSI) benefits? Yes No

Has applicant applied for Medicaid?	Yes No
Has applicant been approved for Medicaid?	Yes No

If Yes, Medicaid #:

County:

Father's Name:

Mother's Name:

Religion:

Church:

Applicant/Spouse a Veteran? Yes No

Previous Occupation:

Funeral Home:

Statement of Applicant's Resources

Monthly Income	Applicant	Spouse
Social Security:
Retirement/Pension:
Regular Salary:
Dividends/Interest Income:
Supplemental Security Income (SSI):
All Other Income:

Total Monthly Income:

Assets	Approximate Value
Primary Residence:
Other Real Estate:
Checking/Money Market Accounts:
Savings/Term Accounts:
Other Assets (stocks, bonds, etc):
Prepaid Funeral:

Total Assets:

Has there been any transfer of funds or assets, including but not limited to real estate in the past 60 months? Yes No
If yes, please provide name:

Have you consulted with an attorney or financial advisor regarding payment for nursing care? Yes No
If yes, please provide name:

Liabilities	Value
Mortgage:
Loans:
Other Liabilities:

Total Liabilities:

To the best of my knowledge and belief, all of the above information is accurate and true. I also warrant that the information provided concerning the applicant's finances are true, correct, complete and accurate, in all material respects and that there are no material omissions.

I agree with the statement listed above

Submitted By:

What is the next whole number after eight?

In compliance with New York State and Federal laws which prohibit discrimination based on race, creed, color, national origin, sex, age, sexual preference, disability, blindness, marital status, sponsorship, employment, or source of payment, this facility admits and treats all patients on a nondiscriminatory basis.

A Rochester Nursing Home serving the Irondequoit, Greece and Rochester Communities

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