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Become a Resident at Pleasant Ridge Manor

Patient General Information

Date Contacted
Adm. Date
Time Expected
Room - Bed
Pt. Type	MCR NON MCR
Field Visit Date
Field Rep.
Patient #
Patient Name (Last, First, MI)
Birthdate
Age
Sex
M.S.
Race
Birth Place
Patient Social Security #
Current Home Address
Township
City, Town
State
Zip
Telephone
Previous Home address
City, Town
State
Zip
Present Location
City, Town
State
Zip
Telephone
U.S. Citizen	Birth Marriage Naturalization Alien
Alien Reg #
Ed-Yrs
Religion
Church
Patient Father (First, Last)
Birth Place
Patient Mother (First, Last)
Birth Place
Spouse (last, First, Mi)
Date of Birth
Maiden Name
Deceased	Yes No
Date Deceased
Spouse Social Security #
Patient Usual Occupation
Spouse Usual Occupation
Military Service
VA Claim #
Referring Person
Relationship
Address
City, State, Zip
Refering Person
Relation
Address
City, State, Zip
Reason for Placement
Living With
Telephone
Patient’s Physician
Telephone

Social Security Supplemental Social Security Income
Direct Deposit Account
Amount
Payee
Pension(Company Name)
Direct Deposit Account
Amount
Payee
VA Pension (Claim No.)
Direct Deposit Account
Amount
Payee
Dividends and interest
Amount
Payee
Other Monthly Income(Rental,Land Contract)
Rental Income
Land Contract Income

Checking Account No.
Name and Address of Bank
Amount
Payee
Checking Account No.
Name and Address of Bank
Amount
Payee
Savings Account No.
Name and Address of Bank
Amount
Payee
Bank Name
CD #
Name & SS on Account
Bank Name
CD #
Name & SS on Account
Stocks and Bonds(Company), Savings Bonds
Amount
Payee
Cash on Hand(Home, Safe Deposit Box,)
Amount
Payee

Does the applicant Own Real Estate? If Yes, Give Location.	yes no
Location
What is approximate Value
Liens	yes no
Liens Held By
Does the applicant Own Rental Property? If Yes, Give Name and Address.	yes no
Name and Address
Has Property been transferred within the Past 36 Months? If Yes, Give Specifics	yes no
Name and Address
Has Property been transferred within the Past 36 Months? If Yes, Give Specifics	yes no
Name and Address
Do you own any motor vehicles? If yes, list make and model.	yes no
Make, Model
Registration #

Company
Policy No.
Face Value
Cash Surrender Value
Beneficiary
Company
Policy No.
Face Value
Cash Surrender Value
Beneficiary
Company
Policy No.
Face Value
Cash Surrender Value
Beneficiary
Comments
Prepaid Burial? If Yes, Specific Amount and Funeral Home	yes no
Amount
Funeral Home