Charlton Manor Rest Home

Confidential Application for Residency

Please correct the errors described below.

I. General Information

Applicant Name

II. Resident Profile

In case of an emergency or a necessity, whom should we call?

Next of Kin (if different than above)

III. Current Living Situation

IV. Medical and Insurance Information

Please list all of your medical insurance coverages, including supplemental and long-term care

Policy #1

Policy #2

V. Daily Living

Is there any other information we should be aware of when reviewing your health and medical concerns?

Income Sources

The following worksheet is necessary to determine if your financial resources are adequate to cover the monthly living costs at Charlton Manor Rest Home. This information is kept confidential and can be used to determine if you may be eligible for our Medicaid program.

Please List Any Bank Accounts

Add Another Bank Account

Name and address of "Other Person"

Please describe any Advance Directives you may have in place (i.e. power of attorney, health care proxy, DNR, living will, conservator, guardian) and list name, address, and phone number of person who holds such power. Please furnish a complete copy of the authorizing document, as well as any trust documents, wills and codicils which may pertain to these powers.

Add another Advance Directive

I certify that the information I have given in this application is true and correct. I understand that any false statements, misrepresentations or omissions may result in the cancellation of my application. All information submitted by the applicant will be held in strict confidence.

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