Hills, MN 56138

ALL INFORMATION WILL BE HELD IN CONFIEDENCE. PLEASE ANSWER ALL QUESTIONS.

Date of Application:

  1. Name of Applicant:

(Last) (First) (Middle)(Maiden Name)

Date of Birth: Place of Birth:

  1. Address:

(Street)(City)(State)(Zip)(County)

  1. Social Security #:Medicare #:

(PROVIDE CARDS FOR NURSING HOME TO MAKE COPIES)

  1. Do you have health insurance or supplemental Medicare insurance coverage?

Yes No

Name of Health Insurance/Supplement:

(PROVIDE CARD FOR NURSING HOME TO MAKE A COPY)

  1. Are you a recipient of Medical Assistance?

Yes NoCounty:

If Yes, give M.A. #:

(PROVIDE CARD FOR NURSING HOME TO MAKE A COPY)

  1. Are you a recipient of Veteran’s Benefits?: Yes No

Veteran #: Who is to be notified in case of emergency, changes in resident’s condition, or plan of care?

  1. Do you have any of the following:

Power of Attorney, Guardian, or Other Legal Appointee

Durable Power of Attorney:

(NAME)(Please Provide Copay for Nursing Home)

Medical Power of Attorney:

(NAME)(Please Provide Copay for Nursing Home)

Other Legal Appointee:

(NAME)(Please Provide Copay for Nursing Home)

  1. Emergency Contacts:

1st Contact: Cell Phone #:

2nd Contact: Cell Phone #:

  1. Primary Care Physician:

Affiliated Clinic:

IF AN EMERGENCY OR IF THE ATTENDING PHYSICIAN IS NOT AVAILABLE TO PROVIDE THE SERVICES AS REQUIRED BY FEDERAL OR STATE GUIDELINES, I AUTHORIZE THE DESIGNATED DOCTOR ON CALL AT THIS CLINIC/HOSPITAL TO ASSUME RESPONSIBILITY FOR MY MEDICAL CARE. YES IF NO, LIST CLINIC

  1. Hospital Preference:
  1. Dentist:
  1. Eye Doctor:
  1. Pharmacy Services: Medications will be procured from a local pharmacy. This facility will not be responsible for any errors that might be made by a pharmacy outside the facility in filling resident’s prescriptions. The facility retains the right to obtain emergency medications, as ordered by the attending physician.

Pharmacy Choice:

Lewis Family Drug, Rock Rapids, IA for Long Term Care Facilities

Shopko Pharmacy, Luverne, MN

VA Pharmacy

  1. Funeral Home of Choice: (Name of Funeral Home)
  1. Release of Information:

I authorize release of information to public, radio, television, or other news agencies by the Tuff Memorial Home for reason of admission, discharge, or public relations.

Yes No

CONTACT THE ADMINISTRATOR IF YOU WISH NO TO HAVE YOUR PRESENCE DISCLOSED IN THIS FACILITY.

  1. Photographs:

I agree to allow the Tuff Memorial Home to take a photograph of me for the purpose of identification / Yes / No
I give the Tuff Memorial Home my consent to display photographs/videos of me participating in facility activities in public displays within the facility or in news releases or other information publications provided by this facility / Yes / No
I give the Tuff Memorial Home my consent to display my photographs/videos on social media / Yes / No
  1. Resident’s mail is to be delivered as follows:

All to the Resident

OR

Personal Mail to the Resident

Business Mail (including bill for Nursing Home room & board) forwarded to:

Name:

Address:

Relationship to Resident:

  1. Have you ever been convicted of a Felony? Yes No

Are you a Sex Offender? Yes No

  1. For how long do you estimate your personal resources will be sufficient to provide for your care while a resident here? Months Years
  1. Have you ever lived in another nursing home? Yes No

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It is the policy of the Tuff Memorial Home to provide service to all persons without regard to race, color, national origin, handicap or age in compliance with 45 CFR Parts 80, 84, and 91 respectively. The same requirements are applied to all and there is not distinction in eligibility for or in the manner of providing services. All services are available without distinction to all program participants regardless of race, color, national origin, handicap or age. All person and organizations having occasion either to refer persons for services or to recommend our services are advised to do so without regard to the person’s race, color, national origin, handicap or age.

The person designated to coordinate compliance with Section 504 of the Rehabilitation Act of 1973 (non-discrimination against the handicapped) is the administrator who can be reached at (507) 962-3275.

The Tuff Memorial Home will not deny admission to people with a contagious disease including but not limited to HIV, MRSA, and Hepatitis B, unless the State Health Department has concurred with our decision on a case-by-case basis not to admit.

Social History

  1. Place of Birth:
  1. Level of Education:
  1. Last Regular Occupation of Applicant:

Year Retired:

  1. Ethnic Origin:
  1. Race

White
Black
Hispanic
American Indian
Asian
Other:
  1. Marital Status

Married
Never Married
Widowed
Divorced
Separated
  1. Number of Children Born:

List Living Children Below

(Name)

(Address)

(City)(State)(Zip)

Cell #: Home #: Work #:

Email Address:

Preferred Method of Contact:

(Name)

(Address)

(City)(State)(Zip)

Cell #: Home #: Work #:

Email Address:

Preferred Method of Contact:

(Name)

(Address)

(City)(State)(Zip)

Cell #: Home #: Work #:

Email Address:

Preferred Method of Contact:

(Name)

(Address)

(City)(State)(Zip)

Cell #: Home #: Work #:

Email Address:

Preferred Method of Contact:

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