Masonic Village at Elizabethtown/ Short-term Rehabilitation Application The Masonic Village is a SMOKE FREE community Office 1-800-422-1207/Fax: 717-361-5500/ www.masonicvillages.org
PERSONAL HISTORY
Name: Phone:
Address:
Date of birth: US Citizen: Yes No Sex: Male Female
Marital Status: Spouse’s Name:
Social Security Number: Medicare Number:
Health Insurance: Health Ins. Number:
Are you a Veteran? Yes No If Yes, Branch
Please check off if you have: Financial POA Healthcare POA Living Will Last Will/Testament
Legal Power of Attorney’s Name: Relationship:
Address:
Phone: (H) (W) (C)
Are you affiliated with a Pennsylvania Mason or member of the Eastern Star? Yes No If yes, list your relationship to Mason/OES member & their name
Name of Family Physician: Phone:
EMERGENCY CONTACT INFORMATION
1. Name: Relationship:
Address:
Phone: (H) (W) (C)
E-mail address:
2. Name: Relationship:
Address:
Phone: (H) (W) (C)
E-mail address:
Previous admission to hospital and/or skilled nursing facility this year? Yes No
Hospital/Facility Dates of Stay:
Reason for admission:
Hospital/Facility Dates of Stay:
Reason for admission:
FINANCIAL INFORMATION
Please provide the information below. This information will allow our staff to assist you at the time of discharge, should additional home health or medical equipment be needed. MONTHLY INCOME
SALES/TRANSFERS/GIFTS
Within the past 5 years, immediately preceding the date of this application, have you or your spouse:
Paid bills for anyone other than yourself from your accounts?
Shared accounts with someone other than your spouse?
Placed assets into a Revocable or Irrevocable Family Trust?
Transferred or gifted: real estate, automobiles, monetary gifts, bank acct, stocks/bonds, life ins. or other assets?
Sold real estate, automobiles or other assets under Fair Market Value?
Had money or personal possessions taken without your permission?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
What is the discharge goal for the patient? _____________________________________________
Signature of Applicant and/or person completing this application:
Relationship to Applicant: Date:
Decisions concerning admissions, the provision of services, and referral of residents are not based upon race, religion, color, national origin, ancestry, age (where minimum age for admission is met), sex, sexual orientation, marital status, disability, limited English Proficiency (LEP) or any other protected status.
DOCUMENTATION FOR ADMISSION FILE
The items listed below should be provided to the Admissions Office with your short-term application to the Masonic Village at Elizabethtown.
_____ Medicare card
_____ Supplemental health insurance card or Medicare Advantage Card (copies of front/back)
_____ Power of attorney or guardianship papers
Living will or Healthcare power of attorney
