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Lakeside Nursing and Rehabilitation Center
1229 Trumansburg Road, Ithaca, New York 14850
607-273-8072
ADMISSIONS APPLICATION
Click here to print blank form to complete and mail
Name
First
Middle
Last
Maiden
Email
Where is the Applicant presently?
Home Address
City
State
Zip
Phone Number
Sex
Marital Status
Birth date
Place of Birth
Social Security #
Significant Other 's Name
Physician
Religion
Previous Occupation
Applicant/Spouse a Veteran?
Yes
No
Advance Directives
(A Copy will be requested at the time of Admission)
DNR
Yes
No
Living Will
Yes
No
Health Care Proxy
Yes
No
Name of Your Agent
Funeral Home
(Required)
Phone #
Person To Notify in Case Of Emergency
Name
Relationship
Address
City
State
Zip
Home Phone #
Work Phone #
Cell Phone #
Primary contact/responsible party
Name
Relationship
Address
City
State
Zip
Home Phone #
Work Phone #
Cell Phone #
Other family member/responsible party
Name
Relationship
Address
City
State
Zip
Home Phone #
Work Phone #
Cell Phone #
Financial Information
Medicare #
Medicare Part B?
Yes
No
Medicaid #
County
Other Insurance
Other Health Insurance
Long Term Care Insurance
Bank Accounts
Bank #1
Name
Checking $
Savings $
Bank #2
Name
Checking $
Savings $
Assets
Investments
Real Estate
Other Assets
Life Insurance?
Yes
No
With Whom
Monthly Income
Social Security
$
Pension
$
Veterans Benefits
$
Other
$
Outstanding Debts
$
Person Managing Applicant's Funds
Name
Relationship
Address
City
State
Zip
Home Phone #
Work Phone #
Power of Attorney?
Yes
No
Attestation:
According to the best of my knowledge and belief, the above information is accurate and true in all respects.
Signature of Applicant
By writing your name you hereby agree to the above Attestation
Date
Signature of Applicant
By writing your name you hereby agree to the above Attestation
Date