Admissions Application

Should you have any questions and/or you would like to schedule a tour of our facility, please call Sister Damian, D.M., our Director of Admissions at 717.755.1964. For your convenience, you can complete our admissions application by printing the Admissions Form and emailing it to sdamian@mn-rc.org or via fax at 717.840.0010.

You can also complete the online form below: All fields marked with a RED asterisk are mandatory!

Step 1 of 7

14%

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. All fields with a RED asterisk (*) are required. Thank you.
Personal Data
Name
First Middle Last
Home Address
Street Address Address Line 2 City State ZIP Code
Residing at this Residence Since
Goal Related to This Admission:
- Short-term to home or assisted living
- Long-term
- Uncertain
Now Residing At: (If different than Home Address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Residing at Current (non-Home) Address Since
Place of Birth:
Date of Birth:
Age:
Sex
Marital Status
Race
Name of Spouse
Age
Address of Spouse
If spouce is deceased, date of death
Father's Name
Mother's Maiden Name
Religious Affiliation
Name of Church
Pastor and Phone Number

Medical Information
Name of Physician
Phone
Last Office Visit
Hospital Preference
- York
- Memorial
Date of latest Pneumovax
Facility Transferred From ... and phone number
Most Recent Hospitalizations
Hospital Reason Date
Does applicant have a living will?
- Yes
- No

Financial Data (Assets)
Savings Account 1: Bank Name*
Bank Account Amount
Name(s) on Account
Savings Account 2: Bank Name
Bank Account 2 Amount
Name(s) on Account
Checking Account 1: Bank/Institution*
Checking Account 1 Amount
Name(s) on Account
Checking Account 2: Bank Name
Checking Account 2 Amount
Name(s) on Account
Mutual Funds
Include Bank / Institution, Amount and Name(s) on Account
Certificates of Deposit
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
Individual Retirement 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
State, Township & Municipality
Current Equity Value
Official Name of Ownership ?
Has any real estate, personal property, cash or sticks been transferred by the applicant within the last five years?
- Yes
- No
If yes, please list provide details including amount
Billing 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

Income
Social Security Number*
Monthly Social Security Dollar Amount
Monthly Pensions Received: Dollar Amount
Pensions Received: Source, Contact information and Monthly Dollar Amount
Is Applicant a Veteran?
Is Applicant the Spouse of a Veteran?
What Dates of Active Duty?
Interest Income: Yearly Amount and Source
Other Income: Yearly Amount and Source

Insurance
Medicare # (Please include letter after the number)*
Medicare Hospital (Part A)
Medicare Hospital (Part B)
Medicare Supplemental Insurance: Name
Medicare Suppliment Insurance ID Number
Medicare Advantage Plan: Name
Medicare Advantage ID Plan Number
Medicare Part D Prescription Plan: Name
Medicare Part D prescription Plan ID Number
Other Medical Insurance: Name of Policy
Other Medical Insurance Plans, Name, ID Numbers
Blue Cross: Contract Number
Blue Cross Group Number
Life Insurance Policy: Name
Life Insurance Policy Number
Long Term Care Policy: Name
Long Term Care Policy Number
Long Term Care Policy: Date Policy was Acquired
Long Term Care Policy Face Value
Long Term Care Cash Value

Family - Please provide ALL information below
Medical Power of Attorney: Name
First Last
Relationship to Medical Power of Attorney
MedicalPower of Attorney Phone: Home Number
Medical Power of Attorney Phone: Cell
Medical Power of Attorney Phone: Work
Medical Power of Attorney: Email
Financial Power of Attorney: Name
First Last
Financial Power of Attorney Relationship
Financial Power of Attorney Phone: Home
Financial Power of Attorney Phone: Cell
Financial Power of Attorney Phone: Work
Financial Power of Attorney Email
Name of Applicant's Legal Guardian (if applicable)
First Last
Applicants Legal Guardian Phone: Home
Applicants Legal Guardian Phone: Cell
Applicants Legal Guardian Phone: Work
Applicants Legal Guardian Email
Emergency Contact notify:
First Last
Emergency Contact Relationship
Emergency Contact Phone: Home
Emergency Contact Phone: Cell
Emergency Contact Phone: Work
Recepiant of personal property be released at time of discharge or death?
First Last
Recepiant of Personal Property Relationship
Recepiant of Personal Property Phone: Home
Recepiant of Personal Property Phone: Cell
Recepiant of Personal Property Phone: Work
Other Contacts - Please provide ALL information below
Name
First Last
Other Contact Relationship
Other Contact Phone
Other Contact Email
Additional Contact Name
First Last
Additional Contact Relationship
Additional Contact Phone
Additional Contact Email
Third Contact Name
First Last
Third Contact Relationship
Third Contact Phone
Third Contact Email

Burial Provisions
Financial Source of Burial Funding
Funeral Home
Funeral Home Phone
Cemetary and Location
Does applicant have a Last Will and Testament?
- Yes
- No
Name of the Executator of the Estate
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 Of Individual Filling Out the Application
First Last
Date of Application
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number of Individual Filling out the Application
Relationship to Resident of Individual Who Completed this Form

Hospital	Reason	Date

Misericordia Nursing & Rehabilitation Center

Step 1 of 7

Application for Admission

Personal Data

Medical Information

Financial Data (Assets)

Income

Insurance

Family - Please provide ALL information below

Burial Provisions