Cincinnati Nursing Care » Mount Washington Care Center

Application For Residency

To apply for admission, please complete this questionnaire and submit it. All information will be held in confidence. A more complete medical history and physical exam will be recorded on another form. This application will become a part of the "Resident Agreement".

Tell Us About Yourself

Title:
First Name:
Middle Initial:
Last Name:
: ------------------
Address 1:
Address 2:
City:
State:
Zip:
: ------------------
Phone:
E-mail:
: ------------------
Religion :
Church:
Marital Status:
: ------------------
Date of Birth:
Birth City:
Birth State:
Social Security #:
: ------------------
Medicare #:
Effective Date:
Medicaid #:
Effective Date:
Co-Insurance Name & #:
Effective Date:
Funeral Home:
Pre-Paid :
: ------------------
Person Completing Form:
Relationship To Resident:
Phone #:
Address:
City:
State:
Zip:
How Did You Hear Of Us? :
Have You Visited Another Facility? :
If Yes, Which One?:
: ------------------
Person Completing Form:
Relationship To Resident:
Phone #:
Address:
City:
State:
Zip:
How Did You Hear Of Us? :
Have You Visited Another Facility? :
If Yes, Which One?:
: ------------------
Provide Overall Medical Diagnoses :
Resident's Current Physician :
Physician's Phone # :
Mentally Alert:
Eats Independently:
Ambulatory:
Bed Ridden:
Continent:
Forgetful:
Requires Help with Feeding:
Walks with Assistance:
Requires Bed Rail :
Incontinent:
Confused:
Requires Special Diet:
Chair-Ridden:
Admission Date Desired:
Resident Now Resides at:
Reason for Seeking Admission:
Name Releasing Medical Information:
I agree to the release:
Who Is Finacially Responsible (name):
Phone #:
Address:
City:
State:
Zip:
Has trust account been established?:
If yes, please detail and a copy needed:
Durable Power of Attorney appointed for finacial affairs:
Has a Legal Guardian been appointed?:
Has a Living Will been executed?:
Has a Durable Medical Power of Attorney been appointed?: