120 Rider Avenue, Lancaster, Pa 17603 Ph. 717.397.3000 Fax. 717.585-6008

Resident Application

Name______

Current Address______City______State______Zip______

Phone______Cell______Birthdate______Sex______

Social Security______Religion______Status---M/W/D/S

Race______Height______Weight______Hair______Eyes______

Any identifying marks? Y/N Description______

POWER OF ATTORNEY AND/OR BILLING PARTY

1. Name______Relationship______

Designation: POA/Emergency Contact/Billing Party

Address______City______State_____Zip_____

Home Phone______Work______Cell______

2. Name______Relationship______

Designation: POA/Emergency Contact/Billing Party

Address______City______State_____Zip_____

Home Phone______Work______Cell______

Veteran of US Military? Yes____ No_____ Branch? ______

Insurance Information

Medicare #______or Medicare Advantage Plan ______

Supplemental Insurance Company______

Policy #______Group # ______ID # ______

Pharmacy Coverage Plan______

ID # ______Group # ______

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Medical Information

Hospital Preference ______Ambulance Plan______

Funeral Home______Phone______

Flu Vaccination? Yes/No Date______Pneumovax? Yes/No Date______

Tetanus? Yes/No Date______PPD/Mantoux? Yes/No Date______

Wear Dentures? Yes/No Upper/Lower/Both Glasses? Yes/No ______

Hearing Aid? Yes/No Left/Right/Both

Continent of bladder: Yes/No bowel: Yes/No

Any allergies?______

Ambulation: Walker_____ Cane______Independent______

Use Tobacco? Yes/No Alcohol? Yes/No

Require assistance:

Bathing? Yes/No Toileting? Yes/No Dressing? Yes/No

List hospitalizations within the last year:

Date______Hospital______Diagnosis______

Primary Care Physician______

Address______Phone______

Podiatrist______

Address______Phone______

Dentist______

Address______Phone______

Ophthalmologist/Optician______

Address______Phone______

Specialist______

Address______Phone______

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Financial Statement:

While SLL respects the privacy of every individual seeking admission to our facility, we do reserve the right to make an inquiry into individual financial circumstances. We seek assurance that every individual can manage their own personal obligations in addition to handling commitment necessary to meet our financial requirements. This information will be kept in the most confidential manner.

CONFIDENTIAL FINANCIAL INQUIRY:

Monthly Income:

Social Security $______

Pension $______

Dividends $______

Interest $______

Income from Estate $______

Trust Income $______

Other Income $______

Total $______

Monthly Obligations

Mortgage Payment $______

Car Payment $______

Insurance Premium(s) $______

Credit Card (s) /mo $______

Loan Payment $______

Other Payments $______

Total $______

Assets

Cash (savings/checking)______

Stocks, Bonds, CDs $______

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Real Estate Value $______

Other Real Estate $______

Trusts $______

Money Market Acct $______

Total Assets $______

Do You Have a Power of Attorney? Yes_____ No_____ (please provide copy of POA)

POA Name______Relationship______

Address______City______State______ZIP______

Home Phone______Cell______Work______

Are you assigning someone to make payments on your behalf? Yes______No______

Name______Relationship______

Address______City______State______ZIP______

Home Phone______Cell______Work______

I affirm that the foregoing is a true statement of facts and that it is submitted as part of an application for residency at Senior Living at Lancaster. I understand that I may be asked in the future for additional information. I further understand and acknowledge that I will not transfer or reduce my resources.

Applicant’s Signature______Date______

Payor’s Signature(if assigned)______Date______