Demographics/Financial form for SNF packet
Strong Memorial Hospital Social Work Division
COMMUNITY REFERRAL FORM
|Identifying Information |
|Patient Name Date of birth |
|Home Address Social Security # |
|Sex M F |
|Telephone Religion |
|Military Service Yes No Service Connected Yes No Admission date |
|Service Connection Percentage DNR Yes No |
|Health Care Proxy Yes No Copy Attached |
|PCP/Family MD Name |
|Contacts: |
|Name Relationship Phone: Cell ________________________________ |
|Address Home _____________________________________ |
|Power of Attorney Copy Attached Work |
|Name Relationship Phone: Cell _________________________________ |
|Address Home _____________________________________ |
|Power of Attorney Copy Attached Work |
|Information (include Policy Numbers and Telephone Numbers for No-fault & Commercial Insurances) |
|Medicare: A B Commercial/HMO Plan:__________________________________ |
|Medicare D Plan: Policy #________________________________________________ |
|Medicaid CIN:_____________________________________ SNF Benefit_____________________________________________ |
|Spend Down__________________________________________ Workers’ Comp: ________________________________________ |
|Medicaid HMO: Policy #___________________Phone:_______________________ |
|MA Financial CM Referral Date: ________________________ No Fault/MVA: |
| |
|MA Applic. Date:___________DSS Date__________________ Policy #___________________ Phone:_______________________ |
| |
|Financial Case Manager: ______________________________ Long Term Care Insurance:______________________________ |
|Phone: _____________________________________________ Policy #___________________Phone:_______________________ |
|Financial Information (required to process application) |
|Patient who is: Single Married Separated Divorced Widowed |
| |
|Patient Spouse |
|a) Monthly Income specify amount $ _______________ specify amount $_______________ |
| |
|Salary Pension Other Salary Pension Other |
|Social Security Social Security |
| |
|b) Bank Accounts/Savings/Checking specify amount $ specify amount $ ______________ |
|c) Stocks/Bonds specify amount $ specify amount $ ______________ |
| |
|d) CD’s specify amount $ specify amount $ ______________ |
|e) IRA, 401, 403B specify amount $ specify amount $ ______________ |
| |
|House: Yes No Other Real Estate/Rental Property Yes No If yes, address_________________________________ |
|Spouse or Disabled Adult Child or Child under 21 years old in Home: Yes No |
| |
|Attorney Financial Advisor Name:______________________________ ________Phone:____________________________ |
|Has there been any transfer of funds/property within the last 60 months? Yes No |
|If yes, state amount and reason for transfer: ______________________________________________________________________ |
|Trust Accounts Yes No |
|Amount:_____________________________ |
| |
|Revised kj: 6/27/12 |
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