Form Doh-4397 - Assisted Living Residence Resident Personal Data Form - 2012 Page 2
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2ASSISTED LIVING RESIDENCE
New York State Department of Health
RESIDENT PERSONAL DATA FORM
Division of Assisted Living
Resident’s Name: __________________________________ Facility Name: ____________________________________
SECTION 1: PERSONAL DATA Cont.:
HEALTH INSURANCE
PHARMACY
Insurer _________________________ID # _____________
Pharmacy(ies) _____________________________________
Medicaid No. _____________________________________
__________________________________________________
Medicare No. _____________________________________
Phone ____________________Phone ___________________
Prescription Drug Plan (if any) ________________________
Address(es) ________________________________________
Plan ID # _________________________________________
__________________________________________________
Other Health Care Coverage ________________________
City ______________________ State _______ Zip_________
_________________________________________________
SECTION 2:
PERSONAL BACKGROUND
Wishes to be addressed as: ____________________________________________________________________________________
Address (if different from ALR): _________________________________________________________________________________
Resident’s Representative: ______________________________
Relationship: __________________________________________
Significant Other:____________________________________
Address:______________________________________________
Relationship:________________________________________
______________________________________________
Address:___________________________________________
Phone:
Home_____________________________
___________________________________________________
Work _____________________________
Phone:
Home____________________________
Cell _____________________________
Work____________________________
Cell______________________________
Resident’s Representative: ______________________________
Relationship: __________________________________________
Significant Other:___________________________________
Address:______________________________________________
Relationship:______________________________________
______________________________________________
Address: __________________________________________
Phone:
Home_____________________________
__________________________________________________
Work _____________________________
Phone:
Home _________________________
Cell _____________________________
Work _________________________
Cell _________________________
Residential Background (born/raised, lived most of life):__________________________________________________________
__________________________________________________________________________________________________________
Occupational/Educational Background: _______________________________________________________________________
_________________________________________________________________________________________________________
Religious Affiliation (if any): _______________________ Place of Worship: ___________________ Phone: _______________
Health Care Proxy:
Yes
No __________________________________________
DNR:
Yes
No
(Name)
Power of Attorney:
Yes
No _________________________________________
Living Will: Yes
No
(Name)
Burial Instructions: _________________________________________________________________________________________
___________________________________________________________________________________________________________
DOH-4397 Part A (03/08) Rev. 09/12
Page 2 of 2
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Parent category: Business