Admissions Application

Application for Admission
Thank you for your interest in Admissions at Misericordia. Please complete the form below and we will be in contact with you shortly. Thank you.
Personal Data
Name
First Middle Last
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Goal Related to This Admission:
- Short-term to home or assisted living
- Long-term
- Uncertain
Since ...
Now Residing At: (If different than Home Address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Since ...
Place of Birth:
Date of Birth:
Age:
Sex
Marital Status
Race
Name of Spouse
Age
Address of Spouse
If deceased, date of death
Father's Name
Mother's Maiden Name
Religious Affiliation
Name of Church
Pastor and Phone Number

Financial Data (Assets)
Savings Account 1: Bank/Institution*
Amount
Name(s) on Account
Savings Account 2: Bank/Institution
Amount
Name(s) on Account
Checking Account 1: Bank/Institution*
Amount
Name(s) on Account
Checking Account 2: Bank / Institution
Amount
Name(s) on Account
Mutual Funds
Include Bank / Institution, Amount and Name(s) on Account
CD's
Include Bank / Institution, Amount and Name(s) on Account
Stocks
Include Bank / Institution, Amount and Name(s) on Account
Bonds
Include Bank / Institution, Amount and Name(s) on Account
IRA
Include Bank / Institution, Amount and Name(s) on Account
401K
Include Bank / Institution, Amount and Name(s) on Account
Real Estate Owned by Applicant
Twp/Boro
Current Equity Value
Whose name is on the deed?
Has any real or personal property, including cash been transferred by the applicant within the last five years?
- Yes
- No
If yes, please list provide details including amount
Who will be receive billing and financial information?
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Medical Expenses: Please list monthly Health Care Premiums along with other medical expenses

Family - Please provide ALL information below
Medical Power of Attorney: Name
First Last
Relationship
Phone: Home
Phone: Cell
Phone: Work
Email
Financial Power of Attorney: Name
First Last
Relationship
Phone: Home
Phone: Cell
Phone: Work
Email
Name of Applicant's Legal Guardian (if applicable)
First Last
Phone: Home
Phone: Cell
Phone: Work
Email
In Case of Sickness or Death, notify:
First Last
Relationship
Phone: Home
Phone: Cell
Phone: Work
To whom should personal property be released at time of discharge or death?
First Last
Relationship
Phone: Home
Phone: Cell
Phone: Work
Other Contacts - Please provide ALL information below
Name
First Last
Relationship
Phone
Email
Name
First Last
Relationship
Phone
Email
Name
First Last
Relationship
Phone
Email

Burial Provisions
Financial Source or Burial Trust Funds
Funeral Home
Phone
Cemetary
Does applicant have a Last Will and Testament?
- Yes
- No
Who is Executor?
Please share how you heard about our services?
What is the primary reason why you chose our services?
Applicant hereby certifies that this information is complete, true and correct to the best of his/her knowledge and belief and that he/she has not intentionally withheld or omitted any requested information. Omission or falsification of information may result in rejection of application, denial or admission, or discharge from this facility.
Name
First Last
Date
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Relationship to Resident

Misericordia Nursing & Rehabilitation Center