Leeway - Leaders in AIDS Care

Client Name *

Address *

Phone *

Social Security # *

DOB *

Gender *

Male

Female

Transgendered

U.S. Citizen *

Yes

No

Place of Birth *

Religion *

Veteran *

Yes

No

Emergency Contacts

In case of emergency, contact

(note relationship)

Address

Home Phone

Work Phone

Cell Phone

POA

Conservator

Address

Home Phone

Work Phone

Cell Phone

Insurance Information

Note: Leeway Inc. cannot accept applicants who are uninsured

Applicant Seeking

Short Term Placement

Long Term Placement

(Choose one)

Medicaid #

Pending as of

Is Client on a spend-down?

Yes

No

(Circle one)

Medicare A

Medicare B

Medicare D

(policy number and coverage type, pharmacy)

Private Insurance Company

Policy #

Phone

Fax

Medical Information

Why does the applicant need 24-hour nursing care?

Attending Physician

Physician available to discuss clinical issues of this applicant?

Yes

No

Pager

Phone

Hospital Admission Date

Hospital

Diagnosis

Other diagnoses

(Including HIV-related, with dates)

Advance Directives?

Yes

No

Code Status

DNR/DNI

FULL

PASRR done?

Yes

No

(circle one)

Result

A copy of the PASRR is required at time of admission.

Chest X-ray done?

Yes

No

Chest X-ray result

A copy of X-ray report is required.

Most recent PPD test

Date

Result

Most recent CD4/Viral Load

Date

Infection control issues

Special Diet

Discharge Plans

Where will patient go after completing treatment at Leeway?

Agency Information

Name of person completing form

(Please print)

Relationship to applicant

Agency

Phone

Fax

Beeper

Date

Captcha *

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Skilled Nursing Facility Application

If you would prefer to download the application and fill it out, please click here to DOWNLOAD the file