ASSISTED LIVING RESIDENCE RESIDENT PERSONAL DATA FORM

Transcription

1 New York State Department of Health Division of Assisted Living ASSISTED LIVING RESIDENCE RESIDENT PERSONAL DATA FORM Resident's : Facility : ADMISSION / DISCHARGE INFORMATION Date of Admission: County: Admitted from: 1 Own Home 11 Hospital r NH 1 OMH 1 Other (specify): Admitted from (Street, City, State, Zip): Discharge Date: Discharge to: H Own Home H Hospital H NH H OMH Other (Specify): Discharged to (Street, City, State, Zip Code): Reason for Discharge: SECTION 1: PERSONAL DATA Date of Birth: / / Gender: CM CF Status: Married (Single Divorced Widowed Partner Month Day Year NOTIFY IN CASE OF EMERGENCY Relationship Home: Work: Other: ATTENDING PHYSICIAN OTHER HEALTH CARE PROVIDERS City State Zip OTHER HEALTH CARE PROVIDERS AREA HOSPITAL / CLINIC OF CHOICE Additional Information: DOH-4397 Part A (03/08) Rev. 09/12 Page 1 of 2

2 New York State Department of Health Division of Assisted Living Resident's : Facility : ASSISTED LIVING RESIDENCE RESIDENT PERSONAL DATA FORM SECTION 1: PERSONAL DATA Cont.: HEALTH INSURANCE PHARMACY Insurer ID # Pharmacy(ies) Medicaid No. Medicare No. Phone Phone Prescription Drug Plan (if any) Plan ID # (es) Other Health Care Coverage SECTION 2: PERSONAL BACKGROUND Wishes to be addressed as: (if different from ALR): Resident's Representative: Significant Other: : : Home Work Home Work Resident's Representative: Significant Other: : : Home Work Home Work Residential Background (born/raised, lived most of lifer Occupational/Educational Background: Religious Affiliation (if any): Place of Worship: Health Care Proxy: Yes A No DNR: U Yes A No () Power of Attorney: U Yes U No Living Will: Yes U No U () Burial Instructions: DOH-4397 Part A (03/08) Rev. 09/12 Page 2 of 2

3 New York State Department of Health Division of Assisted Living ASSISTED LIVING RESIDENCE RESIDENT EVALUATION Resident's : Facility : Date of Evaluation: SECTION 6: ADMISSION DECISION ACCEPTED TO: 0 ALRIAHIEHP 0 Enhanced ALR DSpecial Needs ALR Upon admission, the following documents were provided to the applicant at, or prior to, the admissions interview: Consumer Information Guide Copy of the Residency Agreement Copy of the statement of resident rights Copy of any facility regulations relating to resident activities, office and visiting hours and like information If made available to the operator by the Long-Term Care Ombudsman Program, a fact sheet about the program and the listing of legal services or advocacy agencies. Personal Allowance Protections (SSI and Temporary Assistance (TA) recipients only) Most recent Statement of Deficiencies (shown to applicant) Signature(s) of ALR staff participating in this evaluation. : Title: Date: : Title: Date: : Title: Date: Signature of Administrator/Case Manager/or ISP Planner: Signature of Individual/Resident: Signature of Resident Representative: Date: Date: Date: (s) of others participating in this evaluation. : Date: : Date: DOH-4397 Part B (03/08) Rev. 09/12 Page 6 of 6

4 Senior Living Community 555 Maiden Lane, Rochester, New York Phone (585) Fax (585) Information In an effort to reduce the use of paper we are asking for the address of the Resident Representative so we are able to send electronic communications. This will provide us an efficient way to keep you informed of upcoming events as well as any other important news at GrandeVille. Thank you for your cooperation. Resident Representative LOCALLY OWNED AND OPERATED SINCE 1974

5 GrandeVille Senior Living Community 555 Maiden Lane, Rochester, New York Phone (585) Fax (585) Personal Worth Statement : : Social Security Number: I. INCOME (Please write YES or NO in every space provided below. Fill in monthly amounts as applicable) Do You Receive? YES or NO Income Source Amount per month Social Security $ VA Pension $ Retirement/Pension $ Alimony $ SSI $ Rental Property $ Other $ Please list any other sources of income: TOTAL MONTHLY INCOME: $ II. ASSETS (Please write YES or NO in every space provided below. List amount of asset where applicable) YES or NO Asset Asset Value Account # Checking Account(s) $ Savings Account (s) $ CDs $ Stocks $ Bonds $ IRAs $ Notes $ Property $ Money Market $ Other $ Please list any other assets: Life Insurance Cash Value $ or N/A TOTAL CURRENT ASSETS: $ 1

6 Do you have Long Term Care Insurance? yes no III. LIABILITIES: YES or NO Liability Monthly Payment Total Owed Bank Loans $ $ Taxes Due $ $ Mortgage $ /Value Health Insurance $ N/A Prescriptions $ N/A Phone $ N/A Cable $ N/A Auto Loan $ /Value Auto Insurance $ $ Other: $ $ TOTAL LIABILITIES: Monthly: $ TOTAL $ IV. PERSONAL NET WORTH (Total Assets minus Total Liabilities): $ Please submit proof of income source and assets with this application. Resident (Please Print) Resident Signature Resident Representative (Please Print) Resident Representative Signature GrandeVille Representative (Please Print) GrandeVille Representative Dated this day of, 2. 2