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Serving Southern Orange County, NY
and Sussex & Passaic Counties, NJ.

 

 


 

Family Information
(*) Required Fields  

*First Name:

 

*Last Name:

 
*Social Security #:
  
*Address:
  
*City:
  
*State
  
*Zip Code:
  
Email:
  
*Phone:
  
Fax:
  
Place of Birth:
 
Date of Birth:
 
Are You Married?:
Yes No  
Please answer the following if you selected No to the above question:
Single Divorced Widowed  
Name of Husband or Wife:
  
Address if living:
  

City:

 

State

 

Zip Code:

 

Persons to Contact in Emergency

  

1. Name

 

Address:

 

City:

 
State:
  
Zip Code:
  
     
2. Name
 
Address:
  
City:
  
State:
  
Zip Code:
  
     
3. Name
 
Address:
  
City:
  
State:
  
Zip Code:
  
     
Present Location of Applicant:
  
Personal Information
  
With whom are you living now?:
  
Relationship:
  
Describe your situation (i.e. own home, rental, 3rd floor walk up apartment):
  

Your profession or occupation
(previous, if retired):

  
Educational background:
 
How did you hear about us?:
  
Do you wish to remain active in your present religious group?
 Yes No  
If so, what is your religion?
  
What are your special interests?
(hobbies, music, art, birds...):
  
Additional information about yourself that we should know:
  
What are the major goals, skills or abilities you want to improve?:
  
Health History
  
1. Give dates and nature of any major illness or operations you have experienced
in the last ten years.
  
Previous Illnesses/Surgery/Hospitalization When
1.
2.
3.
4.
 
Family History
  
Hypertension:
 Yes No
Cancer:
 Yes No
Heart Disease:
 Yes No
COPD:
 Yes No
Epilepsy:
 Yes No
TB:
 Yes No
Diabetes:
 Yes No
Other (specify):
 
Medication History
  
Name of Drug
Dose & Time/Freq
Last Dose Taken
Patient’s Understanding
of Medication
1.
2.
3.
4.
5.
6.
 
Present diagnosis:
  
Name of present physician:
  
Address:
  
City:
  
State:
  
Zip:
  
Telephone#:
  
Have you ever been treated for any nervous or mental disorders?:
 Yes No  
If yes, when?:
  
Name of physician who treated you?:
  
Address:
  
City:
  
State:
  
Zip:
  
Telephone#:
  
Can you walk without assistance?
 Yes No  
If no, what kind of assistance to you need?:
  
Can you completely care for yourself without assistance?:
 Yes No  
Bathe?:
 Yes No  
Dress?
 Yes No  
Use Restroom?:
 Yes No  
Financial Statement
  
Monthly Income List Pension Source & Amount  
Social Security:
 $
Source:
Veterans Benefits:
 $
Amount:
 $
R.R. Retirement:
 $  
Dividends/Interest:
 $  
Trust Income:
 $  
Rental Income:
 $  
Other:
 $  
 
Bank Accounts    

1. Name of Bank:

 

Address:

 

City:

 
State:
  
Zip Code:
  
Acct#:
  
Title of Acct:
  
Balance:$
  
     
2. Name of Bank:
 
Address:
  
City:
  
State:
  
Zip Code:
  
Acct#:
  
Title of Acct:
  
Balance:$
  
     
Stocks and Bonds    

1. Name of Company:

 

Number of Shares:

 

Approximate Value:

 
     
2. Name of Company:
 
Number of Shares:
  
Approximate Value:
  
     
3. Name of Company:
 
Number of Shares:
  
Approximate Value:
  
Real Estate    

1. Location:

 
Approximate Value :$
  
     
2. Location:
  
Approximate Value :$
  
     
3. Location:
  
Approximate Value :$
  
NOTE: Please provide documentation of the above financial information. All information on this application is CONFIDENTIAL.  
Life Insurance    

Name of Company:

 

Type of Policy :

 

Policy Number :

 
Face Value:$
 
Cash Value:$
 
Beneficiary:
  
Any Other Assets Not Included Above  
Description:
  
Approximate Value:$
 
List All Debts, Mortgages and Obligations  

1. Payments Made To:

 

Total Owed:

 

Monthly Payments:

 
     
2. Payments Made To:
 
Total Owed:
  
Monthly Payments:
  
     
3. Payments Made To:
 
Total Owed:
  
Monthly Payments:
  
Health Insurance    
Type
Policy #
Monthly Premium
Medicare A:
 Yes No
$
Medicare B:
 Yes No
$
Medicaid:
 Yes No
$
Blue Cross/
Blue Shield:
 Yes No
$
Other:
$
Other:
$
Additional Information
    Date:
Have you applied for Medicare?:
 Yes No
Have you applied for Medicaid?:
 Yes No
 
Person Responsible for Payment of Bills - Financial Guardian - Power of Attorney:  
Name:
  
Address:
  
City:
  
State:
  
Zip Code:
  
Telephone#:
  
Relationship:
  
I certify that the foregoing is a true and complete statement of my assets and liabilities and understand that MOUNT ALVERNO CENTER will act in reliance upon it.

I hereby authorize MOUNT ALVERNO CENTER to contact my financial references if necessary to verify the information contained in this statement.

I authorize MOUNT ALVERNO CENTER to pursue third party reimbursement and to make available such information of my medical and financial status as is appropriate.

MOUNT ALVERNO CENTER WILL NOT DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, CREED, SEX, SEXUAL PREFERENCE, AGE, DISABILITY, NATIONAL ORIGIN, RELIGION, MARITAL STATUS OR SOURCE OF PAYMENT.		  

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St. Anthony Community Hospital
15 Maple Ave, Warwick, NY 10990
(845) 986-2276