Mary, Queen and Mother - Cardinal Ritter Senior Services

On the Cardinal Carberry CampusMARY, QUEEN AND MOTHER CENTER7601 Watson Road St. Louis, Mo. 63119 Phone(314) 961-8000In order to be considered for admittance into Mary, Queen and Mother Center,the following application must be filled out completely as directed. Please PRINT in INK.Date of Application_____________________________ Referred by_______________________________Name_________________________________________ Preferred Name___________________________Address_______________________________________ Home Phone (_)________________________City/St/Zip________________/_____/______________ Religion__________________________________Present Location (if not at home)__________________________________________________________Date of Birth _____/_____/______Age___________Social Security # _________________________Education_____________________________________ Former Occupation_______________________Military Service Branch_________________________ U.S. Citizen (circle) Yes NoMarital Status (circle) M W D SSpouse’s Name___________________________----------------------------------------------------------------------------------------------------------------------------------------If any of the following persons has Power of Attorney, please indicate POA for relationship.Healthcare Responsible Party _______________________________Relationship__________________Address________________________________________ Home Phone (____)____________________City/St/Zip _______________/______/_______________ Work Phone (____)____________________E-mail (optional):________________________________Financial Responsible Party _________________________________Relationship_________________Address________________________________________ Home Phone (____)____________________City/St/Zip _______________/______/_______________ Work Phone (____)____________________Other Contact______________________________________________Relationship________________Address________________________________________ Home Phone (____)____________________City/St/Zip _______________/______/_______________ Work Phone (____)____________________Mary, Queen and Mother Center · 7601 Watson Road · St. Louis, Missouri 63119 · Phone: 314-961-8000 ·

IF APPLYING FOR PRIVATE PAY CARE,The following information must also be completed prior to admission. The information isrequested in order to identify the applicant’s financial sources and to plan long-term financialobligations. All information given is strictly confidential.ASSETS:Checking AccountSaving AccountCertificates of DepositIndividual Retirement AccountsInvestmentsFunds in TrustHome (approximate value)Other Real Estate (approximate value)Other Assets(A) TOTAL ASSETS$____________$____________$____________$____________$____________$____________$____________$____________$____________$____________LIABILITIES:Home Mortgage (remaining balance) $____________Installment payments (remaining balance)$____________Other Liabilities$____________(B) TOTAL LIABILITIES$____________MONTHLY INCOME:(A)-(B)=NEW ASSET BALANCE $____________Social Security Veteran’s BenefitsPrivate PensionInterest/Dividend IncomeAnnuity IncomeTrust IncomeFrom Other PartiesOther (specify)___________________TOTAL MONTHLY INCOME$____________$____________$____________$____________$____________$____________$____________$____________$____________PLEASE TURN TO THE BACK COVER FOR THE NECESSARY SIGNATURE.3Mary, Queen and Mother Center · 7601 Watson Road · St. Louis, Missouri 63119 · Phone: 314-961-8000 ·

************************************************************************************************Mary, Queen and Mother Center considers all applications regardless of religion, sex, race ornational origin.********************************************************************************STATEMENT OF APPLICATIONApplicant and/or Responsible Party are responsible for ensuring that Mary, Queen and MotherCenter receives payment for all charges for Applicant’s care and stay when due during the periodin which Applicant is a private pay resident. If the Responsible Party is an individual other thanthe Applicant, the Responsible Party is liable for all charges incurred pursuant to this Agreementonly to the extent that the Responsible Party has control over the money or assets of the Applicant.However, the Responsible Party shall be personally liable for any amounts due pursuant to thisAgreement:(i)(ii)if the Responsible Party voluntarily agrees to be personally liable: orif the Applicant has funds available to pay those amounts, but Responsible Partywithholds, misappropriates for personal use or otherwise does not turn over the funds toMary, Queen and Mother Center for payment.Applicant and/or Responsible Party is obligated to apply for Medicaid benefits and any otherthird-party benefits available to Applicant at such time as Applicant’s resources are no longersufficient to pay all of Mary, Queen and Mother Center’s charges for Applicant’s care and stay asa private pay resident. The Applicant and Responsible Party shall at all times cooperate fullywith Mary, Queen and Mother Center and each third-party payor to secure payment.Cooperation includes, when requested, providing information, signing and delivering documentsand designating Mary, Queen and Mother Center, to the extent permitted by law, as theApplicant’s representative payee for receipt of Federal Social Security benefits or any otherfederal or state governmental assistance, or other third-party reimbursement or benefits to theextent of all amounts due Mary, Queen and Mother Center.I hereby voluntarily apply for admission to Mary, Queen and Mother Center. If I am admitted tothis facility, I agree to comply with its rules and regulations, responsibilities and by-laws that mayfrom time to time be established by it. I also expect the same considerations of rights stipulated inthe resident’s Bill of Rights and Responsibilities. I understand that if admitted, I am to remain atthe Center only as long as my stay is agreeable both to Mary, Queen and Mother Center and tome. Either of us has the absolute right to terminate my residence at any time, for any reasonsatisfactory to either of us.I do warrant that all the foregoing statements, representations, and declarations made by me aretrue; that I have fully and fairly answered each question therein contained and that I have notconcealed or misrepresented any material fact.Signed_____________________________________________________Date_______(Applicant or Financial Responsible Party)4Mary, Queen and Mother Center · 7601 Watson Road · St. Louis, Missouri 63119 · Phone: 314-961-8000 ·

On the Cardinal Carberry CampusMary,Queen and Mother Center 7601 Watson Rd. St. Louis, MO 63119 314-961-8000 314-961-3580PHYSICIAN’S MEDICAL EVALUATIONPLEASE PRINT OR TYPE ALL ENTRIESName: ____________________________________ D.O.B. ____/___/___ Date ___/___/___Currently Lives: __Alone __With Family __In another Facility _____________________ALLERGIES: Medications _____________________________Foods __________________DATE OF IMMUNIZATIONS: Flu ________ Pneumovax ________ Tetanus ________DATE OF LAST PPD: _________ Free of COMMUNICABLE DISEASE: ___YES ___ NOCHEST X-RAY REPORT: ______________________________________________________________________________________________________________________________CURRENT DIAGNOSIS:1. _______________________ 2. _______________________ 3. _____________________4. _______________________ 5. _______________________ 6. _____________________PAST & CURRENT MEDICAL/SUGRICAL HISTORY: _____________________________________________________________________________________________________________________________________________________________________________________CURRENT POSITIVE FINDINGS OF REVIEW OF SYSTEMS: _________________________________________________________________________________________________________________________________________________________________________________DOES PATIENT NEED HELP WITH ADL’s?Dressing: YES NO Bathing: YES NO Eating: YES NO Transferring: YES NOMOBILITY: ___Independent ___Cane ___Walker ___Wheelchair(Circle) Electric ManualHow often does he/she use an assistive device?___Occasionally ___Half-time ___All the timeSIGHT IMPAIRED: __ YES __NOHEARING LOSS: __ YES __NOWears glasses __ YES __NO ___Partial __One hearing aidImpaired w/glasses __YES __NO__ Two hearing aids___Complete Amount of loss w/aid(s) ____%PHYSICAL EXAMINATION: BP_____ T _____ P _____ R _____ HT _____ WT _____HEENT: _____________________________________________________________________HEART/LUNG: _______________________________________________________________ABDOMEN: __________________________________________________________________LYMPH GLANDS: ____________________________________________________________RECTAL: ____________________________________________________________________SKIN: ________________________________________________________________________MUSCULOSKELETAL: ________________________________________________________NEUROLOGICAL: _____________________________________________________________Mary, Queen and Mother Center · 7601 Watson Road · St. Louis, Missouri 63119 · Phone: 314-961-8000 ·

NAME: __________________________________PHYSICIAN’S MEDICAL EVALUATIONPAST & CURRENT BEHAVIOR/SOCIAL HISTORY: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PAST & CURRENT BEHAVIOR/SOCIAL HISTORY: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PAST & CURRENT MENTAL HEALTH HISTORY: ________________________________________________________________________________________________________________________________________________________________________________________Is patient confused/disorientated: __Never __Sometimes __Frequently __UsuallyROUTINE MEDICATIONS________________________________________________________________________________________________]__________________]___________________]______________________________________]__________________]___________________]______________________________________]__________________]___________________]___________________PRN MEDICATIONSPAIN SEDATIVES LAXATIVES______________________________________________________________________________________________________]_______________________________]_____________________________________________]_______________________________]_____________________________________________]_______________________________]____________________OTHER MEIDCATIONS OR TREATMENTS: _________________________________________________________________________________________________________________Is patient CONTIENENT OF BLADDER? __Always __Usually __Sometimes __SeldomIs patient CONTIENENT OF BOWEL? __Always __Usually __Sometimes __SeldomDIET AND/OR DIETARY RESTRICTIONS: _____________________________________TREATMENT ORDERS and for WHAT CONDITIONS:______________________________________________________________________________________________________________________________________________________________________________________TREATMENT GOAL and PLAN: _________________________________________________________________________________________________________________________________________________________________________________________________________PROGNOSIS: GOOD ____ FAIR ____ POOR ____ GUARDED ____PHYSICIAN’S NAME (print):_____________________________PH#___________________PHYSICIAN’S SIGNATURE: ____________________________ DATE: ________________(circle) I will / will not visit this patient at the Center(circle) I am willing to continue to see this patient at my office. ___YES ___NOMary, Queen and Mother Center · 7601 Watson Road · St. Louis, Missouri 63119 · Phone: 314-961-8000 ·