Form Uhss 2.1-1 - Application For Admission Page 2
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3Funeral Arrangem ents
Funeral Home or Person Responsible for Funeral
Name
Address
Phone Number
I nsurance Coverage
Medicare #
PDP (Prescription Drug Plan)
Medicaid #
County
Medicaid Applying Yes No
Blue Cross/Blue Shield ID #
Policy #
Plan #
Veteran
Yes No
Spouse of a Veteran Yes No
VA#
Other Medical Coverage (Include Long Term Care Coverage or Hospice)
Insurance Company
Address
Policy/Group Numbers
Financial Resources (am ount per m onth)
Social Security
$
Railroad Retirement
$
Retirement Pension
$
Dividends
$
SSI
$
Interest
$
Veterans Pension
$
Other Income
$
Bank Accounts
Name and Address of Bank
Type of Account (Checking, Savings, CD’s, etc.)
Balance
Do you have a Representative Payee for your Social Security checks? Yes No If yes, Name
Do you have your “Letter of Creditable Prescriptions Drug Coverage Notice?” Yes No
Do you have a Power of Attorney? Yes No
If yes, Name
Person responsible for payment of care
Signature of Applicant or Representative
Date
FEDERAL AND STATE LAWS PROHIBIT RESIDENTIAL HEALTH CARE FACILITIES FROM DENYING ADMISSION TO
ANYONE BECAUSE OF RACE, CREED, COLOR, PLACE OF BIRTH, SEX, DISABLITIY, BLINDNESS, SOURCE OF
SPONSORSHIP, SOURCE OF PAYMENT, MARITAL STATUS.
01/19/15
Form UHSS 2.1-1
Page 2 of 3
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Parent category: Medical