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To apply for residency at Baptist Homes, please complete our application form.

 

* Indicates required field

Contact Information
Name of Applicant*
Birthdate*
Street Address*
City*
State*
Zip*
Phone*
Marital Status*
Name of Spouse

  Living Deceased
Social Security Number*
Medical Assistance Number
Primary Insurer Name*
Number
Secondary Insurer Name
Number
Long Term Care Insurance
Policy Number
For what level are you applying ? Assisted Living
Nursing Center
Alzheimer’s Special
Care Center
Reason you are making application at this time
 
What is the general state of your health?
Please list major problems
Name of Physician
Phone Number
Will you consent to your physician's releasing information to Baptist Homes regarding your health and medical needs? Yes
No
Your hospital preference?
Do you have a living will? Yes
No
   
Financial Information  
Monthly income:
Pension:
Social Security:
SSI:
Investment Income:
Other:
Total Monthly Income:
Fixed On-going Monthly Liabilities
(Please list type and amount):
(Assisted Living Applicants Only - Please mail a copy of your most recent 1040 tax return. Because there are no programs for federal assistance for the assisted living residents who cannot pay for their care, and because of our commitment to providing benevolent care to our current residents who are in need, we must ask for verification of income to ensure our ability to serve each resident in need.)
   
Value of personal assets not including real estate:
Savings Accounts
Checking Accounts
Stocks and Bonds
Trust Funds
Surrender Value of Life Insurance
Pre-Paid Burial
Other
Total Liquid Assets
Value of solely or jointly owned real estate, to your best estimate
Will the sale of this real estate be used to pay for your care? Yes
No
Is anyone other than yourself legally authorized to handle your financial and/or personal matters? Yes
No
If yes, please explain (power of attorney, guardian, etc.)  
Name
Relationship
Address
City
State
Zip
Home Phone
Business Phone
Do you have relatives who plan to assist with your costs of care? If yes, please list name(s) and phone number(s).
Who should recieve billing statements if you become a resident at Baptist Homes? Self
Other
Name
Relationship
Address
City
State
Zip
Home Phone
Business Phone
   

Other Information
In the event that we cannot reach you, please list other family members or friends who may be contacted on your behalf.

Primary Contact:  
Name
Relationship
Address
City
State
Home Phone
Business Phone
   
Other Contacts:  
Name
Relationship
Address
City
State
Home Phone
Business Phone
   
Name
Relationship
Address
City
State
Home Phone
Business Phone
   
Church Affiliation
By what date will you like to live at Baptist Homes?
How did you hear about Baptist Homes?
Other Comments or questions:  
Relationship of Preparer to Applicant
 

This form does not create any contractual obligation between the applicant and Baptist Homes, nor does this bind either party to admission.

Baptist Homes complies with the provisions of the Federal Civil Rights Act of 1964 and the Pennsylvania Human Relations Act and affirms that no person shall, on the grounds of race, color, national origion, religious creed, ancestry, age, sex or handicap, be excluded from participation in or the benefits of any service or care.