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Home
Services
Admissions
- Admissions Process
- Schedule Of Charges
Photo Gallery
Careers
F.A.Q.
Contact Us

Residency Application

Name of Applicant *

First

Last

Address *

City *

State *

Zip *

Telephone # *

Religion

Church

Date of Birth *

Place of Birth *

State *

Social Security Number *

Marital Status *

Single
Married
Widowed

Medicare #

Effective Date

Medicaid #

Effective Date

Coinsurance Policy Co. & No

Effective Date

Funeral Home

Prepaid

Yes
No

Name of Person Completing this Form *

First

Last

Email Address of Person Completing this Form *

Relationship to Resident

Telephone #

Address

City

State

Zip

How did you hear about the Anderson?

Newspaper
Social Worker
Other Nursing Facility
Brochure
Physician
Other
Friend
Hospital

Have you visited Other Nursing Facilities?

Yes
No

If yes, which ones?

Diagnoses

Resident’s Current Physician

Telephone #

Mentally Alert *

Yes
No

Bed-Ridden *

Yes
No

Requires Help with Feeding *

Yes
No

Incontinent *

Yes
No

Chair-Ridden *

Yes
No

Eats Independently *

Yes
No

Continent *

Yes
No

Walks with Assistance *

Yes
No

Confused *

Yes
No

Ambulatory *

Yes
No

Forgetful *

Yes
No

Requires Bed Rails *

Yes
No

Requires Special Diet *

Yes
No

Covid 19 Vaccine status *

Fully Vaccinated
Unvaccinated
Partially vaccinated

Covid 19 Vaccine Booster *

Boosted
Would like booster

Admission Date Desired

Resident Now Residing at

Reason for seeking admission

Name *

First

Last

I give permission for my (applicant’s) doctor/hospital to release Medical Information

The names(s) of the person(s) who will be financially responsible for the cost of the care (the “Guarantor”)

Telephone No:

Address

City

State

Zip

Has a Trust Account been established? *

Yes
No

If yes, please detail

Has a Durable Power of Attorney been appointed for financial affairs?

Yes
No

If yes, please Detail

Has a Legal Guardian been appointed?

Yes
No

If yes, please detail

Has a Living Will been executed?

Yes
No

If yes, please detail

Has a Durable Medical Power of Attorney been appointed?

Yes
No

If yes, please detail

Salary *

Monthly Income

Social Security *

Monthly Income

Pensions/Annuities *

Monthly Income

IRA

Monthly Income

Interest/Dividend

Monthly Income

Rental Income

investments/Others

Cash

Cash (please list bank names and account #’s)

Account # *

Value *

Securities (stocks bonds)

Description

Account #

Value

Real Estate (description and location): (Example: 3 bedroom house; Jones St., Anyplace OH 99999)

Account #

Value

Life Insurance Name

Cash value of Life Insurance

Vested Pension Benefits Description

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Email Portal
Employee Portal

Contact Info

(513) 474-6200 - Main

(513) 312-0007 - Admissions

8139 Beechmont Ave, Cincinnati, OH 45255

info@TheAnderson.com

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