United Church Homes—Skilled Nursing Facilities

UNITED CHURCH HOMES PRE-ADMISSION INQUIRY:

We would be happy to send you more information regarding Four Winds Community

Please complete the information below, and we will be contacting you with more information right away.

Step 1: Contact Info
Applicant's Full Name*
Applicant's Address*
City/State/Zip*
Phone*
Email Address
*Required fields
Step 2: Applicant Details
Marital Status		Spouse's Name
Medicare #*		Insurance #*
Medicaid #*		2^nd Insurance
Applicant's S.S. #*		Gender*	MaleFemale
Birth Date* (mo/day/yr)		Age*
Has applicant been hospitalized in the last*		30 days?60 days?60+ days
If yes, where?*
Applicant's Current Location*
Religious Affiliation
Anticipated Date of Placement* (mo/day/yr)
Anticipated Level of Care (A level of care assessment will be conducted by the facility to determine actual level of care)		Retirement Assisted Living Nursing
Step 3: Preliminary Medical Information
Preferred Hospital		Phone
Physician		Phone
Contact Name		Relationship
Contact Address		Phone
Sponsor/POA Name
Sponsor Address		Phone
Step 4: Method of Inquiry
	Phone Visit Letter Email
Step 5: Referral Source
	Newspaper Church Website Doctor Other Friend Yellow Pages	Which paper?
		Which Church?
		Which site?
		Doctor?
		Please explain:

Step 6: Submit Form
I agree with the following statement: "The information on this form is given voluntarily. The customer realizes completion and submission of this form does not guarantee admission to this facility or acceptance on a waiting list."
	I Agree	Applicant Name*