Skilled Nursing Facility Application If you would prefer to download the application and fill it out, please click here to DOWNLOAD the file If you are human, leave this field blank.Client Name *Address *Phone *Social Security # *DOB *Marital Status *Never MarriedMarriedWidowedSignificant OtherDivorcedGender *MaleFemaleTransgenderedU.S. Citizen *YesNoPlace of Birth *Religion *Veteran *YesNo Emergency ContactsIn case of emergency, contact (note relationship)AddressHome PhoneWork PhoneCell PhonePOAConservatorAddressHome PhoneWork PhoneCell PhoneInsurance InformationNote: Leeway Inc. cannot accept applicants who are uninsuredApplicant SeekingShort Term PlacementLong Term Placement (Choose one)Medicaid #Pending as ofIs Client on a spend-down? YesNo(Circle one)Medicare AMedicare BMedicare D(policy number and coverage type, pharmacy)Private Insurance CompanyPolicy #PhoneFax Medical InformationWhy does the applicant need 24-hour nursing care?Attending PhysicianPhysician available to discuss clinical issues of this applicant?YesNoPagerPhoneHospital Admission DateHospitalDiagnosisOther diagnoses(Including HIV-related, with dates)Advance Directives? YesNoCode StatusDNR/DNIFULLPASRR done?YesNo(circle one)ResultA copy of the PASRR is required at time of admission.Mental Status AlertOriented ConfusedForgetful Unresponsive (circle one)Chest X-ray done?YesNoChest X-ray resultA copy of X-ray report is required.Most recent PPD testDateResultMost recent CD4/Viral LoadDateInfection control issuesSpecial DietDischarge PlansWhere will patient go after completing treatment at Leeway?Agency InformationName of person completing form(Please print)Relationship to applicantAgencyPhoneFaxBeeperDateCaptcha *reCAPTCHA is required.Submit