Gero-Psychiatric Nursing Facility Application Date: 1. Participant Information Name: DOB: Gender: M F Medicaid #: Medicaid LTC: Y N Medicare #: Address: Town: State: Maine Zip: Phone Number: Marital Status: 2. Current Facility Information (if applicable) Facility Name: Street Address: Mailing address, if different: City: County: State: ME Zip: Social Worker/Discharge Planner’s Name: Phone #: Fax #: Email address: Admission date: (mm/dd/yyyy): Current level of care (mm/dd/yyyy): (MED Assessed) Date of PASRR Level II (mm/dd/yyy): 3. Person/Agency Making Referral (if applicable) Name of Person/Agency: Street Address: City: County: State: ME Zip: Phone #: Fax #: Email address: 4. Legal Representative, Guardian, Power of Attorney (Provide a copy of paperwork to OADS with this application) Name: Street Address: City: County: State: ME Zip: Phone #: Alternate Phone #: Relationship to Client:
Gero-Psychiatric Nursing Facility Application Date: 1. Participant Information Name: DOB: Gender: M F Medicaid #: Medicaid LTC: Y N Medicare #: Address: Town: State: Maine Zip: Phone Number: Marital Status: 2. Current Facility Information (if applicable) Facility Name: Street Address: Mailing address, if different: City: County: State: ME Zip: Social Worker/Discharge Planner’s Name: Phone #: Fax #: Email address: Admission date: (mm/dd/yyyy): Current (MED Assessed) level of care (mm/dd/yyyy): Date of PASRR Level II (mm/dd/yyy): 3. Person/Agency Making Referral (if applicable) Name of Person/Agency: Street Address: City: County: State: ME Zip: Phone #: Fax #: Email address: 4. Legal Representative, Guardian, Power of Attorney (Provide a copy of paperwork to OADS with this application) Name: Street Address: City: County: State: ME Zip: Phone #: Alternate Phone #: Relationship to Client:
Admission%20Application%20(Word).docx