Compliments of the Caregiver Class from BJC, hosted by BJC Hospice. Contact us at

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1 Important names, addresses, and phone numbers Name: Social security #: Spouse/Partner s name: Social security number: Address: Date prepared: Tip* Each time you update these forms, you may want to add your initials and date. Copies given to: Emergency contact: Clergy: Accountant: Financial advisor; Insurance Agent: Pharmacy: Preferred hospital: Home health company: Medical supply store: 1

2 Physicians/medical providers Primary Care Physician (medical/family doctor): Special Doctors: Cardiologist (heart): Pulmonologist (lung): Nephrologists (kidney, bladder): Gastroenterologist (bowels, stomach): Rheumatologist (arthritis, bones): Endocrinologist (diabetes, immune system): Oncologist (cancer, blood): Orthopedic (bones): Podiatrist (feet): Ophthalmologist (eyes): ENT (ears, nose, throat, hearing specialist): Chiropractor: Dentist: Infectious Disease: 2

3 Legal documents: (Wills, trust, power of attorney, health care declaration, living will, advanced directives, do not resuscitate orders) Document type: Location of original: Copies given to: Financial Power of attorney: Address: Phone: Medical Power of attorney: Address: Phone: Executor: Address: Phone: Trustee(s): Address Phone: Conservator: Address Phone: Attorney: Firm name: Address: Phone: Insurance information Automobile insurance Disability insurance Homeowner s/renter s insurance Health Insurance Long-Term Care Insurance 3

4 Insurance information (continued) Life Insurance Other Insurance Medicare ID Number: Regional Office Address: Regional Office Phone: Medicaid ID Number: Regional Office Address: Regional Office Phone: Banking Information Bank: Banker/Financial Advisor: Address: Phone: Online User ID: Online Password: ATM Pin #: Account Type: Name(s) on account: Account Number: 4

5 Banking Information (continued) Bank: Banker/Financial Advisor: Address: Phone: Bank: Banker/Financial Advisor: Address: Phone: Credit/Debit Cards Type Of Card: Card Number: Expiration Date: Safe Deposit Box Bank: Box Number: Address: Location of keys: Tip* - Check that another person s name (the caregiver) is on the safety deposit box to avoid problems later gaining access to the contents of the box. Automated Bill Payments & Other Electronic Fund Transfers Account charged or transferred from: Account paid or transferred to: Pensions or Retirement Plans Type: Employer Name: Plan Administrator: Contact: 5

6 Business Interests (Stock, Real Estate, Etc.) Company Name: Type: Address: Phone: Other Financial Obligations (Written, Oral or Fiduciary Obligations) Type: Obligated to: Address: Phone: Mortgage/Lease Obligations Type Of Property: Lender/Lessor s Name: Address: Phone: Automobile Make/Model: Year: Color: VIN #: License Plate #: Title #: Registration/ Renewal Date: Drivers License#/Exp Date: Location of Titles: Repair Facility: Address: Phone: Location of repair records: 6

7 Location of Documents/Property Item: Checkbook and Checkbook Registers: Location: Income Tax Returns: Certificates for CD s, Stocks, Bonds, Annuities: Contracts for Pension, Retirement Account, Employement: Deeds: Leases or Loans: Marriage License: Divorce/Separation Papers: Deferred Compensation; IRA: Titles or Deeds: List of Stored And Loaned Items: Birth Certificates: Military/Veterans Papers: Children s Birth Certificates: Club Memberships: Bills: List of Monthly Payments (Auto, Sewer, Electric ): Burial Plans Contract: Other: Other: Other: 7

8 Funeral Plans/Instructions Disposition of body: Cremation: Burial: Donation of body: Donation of organs: Prepaid funeral arrangements: Funeral Home: Address: Phone: Cemetery: Address: Phone: Plot Location: Deed Location: Pall Bearers: Songs: Speakers/ Eulogy/Preferences/Clergy: 8

9 Medical History Condition or Operation: Date: Current Medical Conditions Disease/Disorder: Date Diagnosed: Treatment: 9