Application for Admission

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Notice: It is the policy of the St. Regis Nursing Home to admit and retain residents without regard to race, color, age, creed, handicap, blindness, source of sponsorship, source of payment, national origin, sex, marital status, or sexual preference.

Please complete all form fields carefully.

Resident's Personal Identification :
Name:
Legal Address:
Phone:
Present Location:
Date of Birth:
Social Security #:
Marital Status:	Married Single Divorced Widowed
Spouse or Significant Other:
Sex:	Male Female
Place of Birth:
U.S. Citizen:	Yes No
Father and Mother's Names:
Religion (optional):
Previous Occupation:
Personal Physician:
Relatives/Friends To Be Notified in Emergency:
Name 1:
Address:
Relationship:
Home/Work Phone:
Name 2:
Address:
Relationship:
Home/Work Phone:
Advance Directives:
Healthcare Proxy:	Yes No
Living Will:	Yes No
DNR Order:	Yes No
Body Donor:	Yes No
Organ Tissue Donor:	Yes No
Insurance Coverage: Copies of the following are requested upon application or admission.
Medicare #:
Medicaid #:
County:
Medicaid Applying:	Yes No
Blue Cross/Blue Shield ID#:
Policy #:
Plan #:
Veteran:	Yes No
Spouse of Veteran:	Yes No
VA #:
Other Medical Coverage (Include Long Term Care Coverage or Hospice):
Insurance Company 1:
Address:
Policy/Group Numbers:
Insurance Company 2:
Address:
Policy/Group Numbers:
Financial Resources:
Social Security:
Retirement Pension:
SSI:
Veteran's Pension:
Railroad Retirement:
Dividends:
Interest:
Other Income (Stocks,Bonds, etc.):
Bank Accounts:
Name of Bank 1:
Address:
Type of Account (Checking, Savings, etc.):
Balance:
Name of Bank 2:
Address:
Type of Account (Checking, Savings, etc.):
Balance:
Do you have a Representative Payee for your Social Security checks?	Yes No
If Yes, Name:
Do you have a Power-of-Attorney?	Yes No
If Yes, Name:
Person Responsible for Payment of Care:
Funeral Arrangements (Funeral Home or Person Responsible):
Name:
Address:
Phone:

FEDERAL AND STATE LAWS PROHIBIT RESIDENTIAL HEALTH CARE FACILITIES FROM DENYING ADMISSION TO ANYONE BECAUSE OF RACE, CREED, COLOR, PLACE OF BIRTH, SEX, DISABILITY, BLINDNESS, SOURCE OF SPONSORSHIP, SOURCE OF PAYMENT, MARITAL STATUS, AGE, OR SEXUAL ORIENTATION.

St. Regis Nursing Home, 89 Grove Street Massena, NY 13662-2199
Telephone: (315) 769-2494 Fax (315) 769-3604

Equal Housing

Application for Admission

Resident's Personal Identification :

Relatives/Friends To Be Notified in Emergency:

Advance Directives:

Insurance Coverage:

Other Medical Coverage (Include Long Term Care Coverage or Hospice):

Financial Resources:

Bank Accounts:

Funeral Arrangements (Funeral Home or Person Responsible):