Resident Number
For Internal Use Only
Name
Middle Name
Preferred Name
Social Security #
Admission Type
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Short Term
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Military Service
Admitted From
Date of Birth
-
Month
-
Day
Year
Age
Civil Status
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Citizenship
Birth Place
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Primary Language
Interpreter Needed?
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Insurance Information
Medicare (HIC)
Medicare Beneficiary ID
Medicaid #
Insurance Name
Insurance Policy #
Part D Policy #
Part D Carrier
Medicare Coverage Part
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Medicare Replacement
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Funeral Home
Name
Address
Street Address
Street Address Line 2
City
State / Province
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Hospital Preference
Name
Physician
Name
Address
Street Address
Street Address Line 2
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Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternate Physician (Specialist)
Name
Address
Street Address
Street Address Line 2
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Postal / Zip Code
Phone Number
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Financial Information
to help determine Medicaid eligibility. Amounts can be approximate at this time. If paying privately this information is not necessary
Monthly Social Security Amount
Monthly Pension Amount
Other Income including spouse’s
Life Insurance Policies
Yes
No
Checking Account – approx. balance
Savings Account – approx. balance
CD’s/Annuities/IRA’s/Assets/etc
Does the applicant own a home or Property
Yes
No
Current Residence
Legal Mailing Address
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Notify In Case Of An Emergency
Note: POA Healthcare should be listed first
#1 Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Business Number
Please enter a valid phone number.
Email
example@example.com
Relationship
#2 Name
Address
Street Address
Street Address Line 2
City
State / Province
Zip Code
Cell Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Business Number
Please enter a valid phone number.
Email
example@example.com
Relationship
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MEMORANDUM OF UNDERSTANDING
Winnebago County
As an applicant for admission of River Bluff, I attest to the following conditions
I am a recipient of Illinois Department of Public Aid. I agree that my monthly income will be sent to the River Bluff address where it will be applied to my care account, with the exception of $30.00 and any health insurance premiums. I agree to notify Social Security and any applicable pension managers of the change of address.
I am a Public Aid applicant and agree to cooperate with IDHFS in supplying all requested information. My Income will be sent to the River Bluff address and all income will be applied to my care account with the exception of the $30.00 personal allowance and any health insurance premiums. I agree to notify Social Security and any applicable pension managers of the change of address. I understand if denied Public Aid funds, I will pay River Bluff at the private pay rate. NOTE: A Public Aid applicant who is denied benefits may be requested to leave the facility.
I am married and my spouse will continue to live in the community after my admission to the facility. I am a Public Aid recipient or applicant. I will turn over to River Bluff any monthly income above the amount IDPA determines will be my spouse’s monthly allowance under IDPA’s spousal impoverishment regulations. I understand if denied Public Aid funds, I will pay River Bluff at the private pay rate. NOTE: A Public Aid applicant who is denied benefits may be required to leave the facility.
In the event I do receive funds that would deem me ineligible for Public Aid funds, I agree to pay River Bluff as billed for one month in advance at the private pay rate for my level of care.
I accept responsibility to pay River Bluff privately. I will pay River Bluff as billed one month in advance at the private pay rate for my level of care. I further agree to pay for any ancillary charges as billed.
I understand that misrepresentation of financial condition or failure to remit the required payment will be grounds for dismissal from River Bluff.
Public Aid #
Applicant
Date
-
Month
-
Day
Year
Representative
Date
-
Month
-
Day
Year
Submit
Should be Empty: