MVE - Short Term Application

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

Marital Status:

Spouse’s Name:

Social Security Number:

Medicare Number:

Health Insurance:

Health Ins. Number:

Are you a Veteran?

Yes

No

Please check off if you have:

Sex:

Male

If Yes, Branch Financial POA

Healthcare POA

Legal Power of Attorney’s Name:

Living Will

Last Will/Testament

Relationship:

Address: Phone: (H)

(W)

(C)

Are you affiliated with a Pennsylvania Mason or member of the Eastern Star?

Yes

No

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?

Hospital/Facility

Dates of Stay:

Reason for admission: Hospital/Facility Reason for admission:

Female

Dates of Stay:

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 Social Security Pension IRA Annuities Other

APPLICANT $ $ $ $ $

ASSETS Checking Savings Money Market Certificates of Deposit IRA Real Estate

SPOUSE $ $ $ $ $

APPLICANT $ $ $ $ $ $

SPOUSE

√ if joint

$ $ $ $ $ $

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?

Yes No Shared accounts with someone other than your spouse?

Yes No Placed assets into a Revocable or Irrevocable Family Trust?

Yes No Transferred or gifted: real estate, automobiles, monetary gifts, bank acct, stocks/bonds, life ins. or other assets?

Yes No Sold real estate, automobiles or other assets under Fair Market Value?

Yes No Had money or personal possessions taken without your permission?

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