Application for Assistance Asset Assessment Residence Application Patient Name * First Name Last Name Date of Birth * MM DD YYYY I hereby request and authorize: To release to: Richardton Health Center The following information is requested: 1. History and physical that includes complete medical history, review of all body systems, specific evaluation of individual’s neurological system in all areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes. If there are abnormal findings, specialist’s evaluations are needed. 2. Comprehensive drug history. 3. The completion of the attached form: ND Level I screening and Level of Care Determination. 4. Recent medical problems/surgeries if not addressed in history and physical. Releasor, its agents and its employees, are hereby relieved any responsibility or liability that may arise from the release of reproduction of such records and/or information. Releasee, its agents and its employees, are hereby authorized to obtain, inspect and reproduce such records and/or information and are hereby relieved of any responsibility or liability that may arise from such actions. This authorization to Releasor and Releasee and this waiver of liability includes, but is not limited to, charts, x-ray, photographs, motion picture films, reports, information, papers, writings, and records concerning both the patient’s physical and mental/emotion condition, whether Releasor now has same or makes or obtains them in the future. Name/Signature * (releasor) First Name Last Name Relationship if other than patient Date of Signature * Today's Date MM DD YYYY Name of Applicant * First Name Last Name Where is individual originally from? * Current home town * Where is individual currently located? * Present mailing address * Address 1 Address 2 City State/Province Zip/Postal Code Country Present Phone * (###) ### #### Gender * Male Female Other Other Gender Please list other gender here. Citizen of the USA * Yes No Marital Status * Married Widowed Divorced Separated Single Complete the next 4 items whether individuals are living or deceased. Father's Name * Mother's Maiden Name * Spouse's Name * Years of Education * Spouse address (if living) * Spouse cause of death (if deceased). * Previous Occupation * Military Service Funeral Home preference (name and address) * Home Church * Minister's Name * Clinic Phone * (###) ### #### Hospital Preference * Pharmacist * Dentist * Advanced Directive * Living Will DPOA for healthcare POA for financial Guardian When do you anticipate nursing home care needed? * Family or friends to be contacted in case of emergency: Name, Address, Telephone (home/work), Relationship * Source of Payment * ND Medicaid Private Pay Medicare Other Payment (OTHER) Please describe: Do you receive medical assistance? * Yes No If yes, in what county do you receive this? Have you ever applied for medical assistance? * Yes No Will you need to apply for medical assistance in the near future? * Yes No Personal Care Needs Check if assistance is needed * Leave home Dress/Undress Taking medications Eating Bath/Shower Stairs Getting to bathroom Transfer from bed to chair Check when applicable * Walks independently Walks independently with device Walks with help of cane, walker, crutch, etc.. Confined to bed/wheelchair Falls frequently Needs assistance to propel W/C Propels wheelchair per self Lack of bowel control Lack of bladder control Vision fair to poor Colostomy/Catheter Hearing fair to poor Vision corrected with glasses Hearing aides Special Diet * Yes No If special diet, please explain. Appetite * Good Fair Poor Name of Person Completing this Form: * Date * MM DD YYYY Best Contact Person * Best Contact Phone # * (###) ### #### Best Contact Email Address * Thank you!Your application has been sent to our residence coordinator.Please contact our office if you have any questions.
