Application

Application for Admission

Applicant's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone Number*

Date of Birth*

Current Age*

Please enter a number from 18 to 150.

Birthplace

Marital Status*

Single
Married
Widower
Widow

Religion

Current/Previous Occupation

Education Level

When would you like to enter Sagepoint?

How did you hear about our facility?

Who should we contact regarding your admission to our facility?

please provide the full name and phone number.

Advance Directives

Do you have...*

Power of Attorney
Durable Power of Attorney
Guardian
Living Will
None of the above

Guardian Name

First Last

Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guardian Home Phone Number*

Guardian Work Phone Number*

Family Information

Please list the names and addresses of your children.

Name

First Last

Address

Home Phone

Work Phone

Name

First Last

Address

Home Phone

Work Phone

Name

First Last

Address

Home Phone

Work Phone

Additional Contacts

Name

First Last

Address

Home Phone

Work Phone

Physician Information

Name of your physician

Do you give permission to discuss your medical history with your physician

Please Note: If your current physician does not have admitting privileges with Sagepoint Care Center, you will need to select another physician from our admitting list prior to admission.

Yes
No

Prior to Admission

Please provide us with copies of the following items:

Items to provide prior to admission

Medicare Card
Social Security Card
Private Insurance Card
Medical Assistance Card
Medical Application Pending
Copy of Advance Directives (Power of Attorney, Living Will, etc.)
Recent Bank Statements (3 months)

Funeral Arrangements

Arrangements must me made with a funeral home. Please provide us with the name and address of your funeral home.

Funeral Home

Address

Street Address City State ZIP Code

Phone

Enter the phone number of the funeral home.

Emergency Contacts

In the event of an emergency, please list two people whom we should contact, in the order that you wish them to be called.

Name

First Last

Address

Street Address City State ZIP Code

Name

First Last

Address

Street Address City State ZIP Code

Name

First Last

Address

Street Address City State ZIP Code

Financial Information

The following information must be provided, regardless of pay source.

Social Security #

Medicare Number

Medicaid Number

Veteran's Case Number

Do you own your own home?

Approximate Market Value

Mortgage Owed

Cash or Checking Account Balance

Savings Account Balance

Stocks and Bonds Value

Loans Owed to You

Monthly Income

Social Security

Retirement

Other Income

Have you transferred any real property or cash to anyone in the past 30 months?

Yes
No

Please provide details

I agree, that if I am accepted as a resident of Sagepoint:

Should the need arise, I will change rooms based on the needs of the facility.
I recognize my financial obligation to pay all doctors fees, hospitalization charges, private duty nursing, and medication charges which I may require that are not covered by state and federal programs.
I will pay monthly, in advance, any charges for which I am responsible.
If my condition becomes such that in the judgment of the health professionals at Sagepoint, I can best be cared for elsewhere, I will accept their recommendation.

I hereby certify that all of the above information is accurate. I give my permission for representatives of Sagepoint to obtain verification of the information given above.

CAPTCHA

Application for Admission

Advance Directives

Family Information

Additional Contacts

Physician Information

Prior to Admission

Funeral Arrangements

Emergency Contacts

Financial Information

Monthly Income

Talk to a Sagepoint Advisor