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Cayuga Ridge Extended Care
1229 Trumansburg Road, Ithaca, New York 14850
607-273-8072


ADMISSIONS APPLICATION
Click here to print blank form to complete and mail

Name  
First
Middle
Last
Maiden
Email
   
Where is the Applicant presently?
   
Home Address
 
City
State
Zip
   
Phone Number
Sex
Marital Status
Birth date
Place of Birth
Social Security #
Significant Other 's Name
Physician
Religion
Previous Occupation
Applicant/Spouse a Veteran?
Advance Directives
(A Copy will be requested at the time of Admission)
DNR

Living Will
Health Care Proxy
Name of Your Agent
   
Funeral Home
(Required)
Phone #
   
Person To Notify in Case Of Emergency
Name
Relationship
Address
 
City
State
Zip
Home Phone #
Work Phone #
Cell Phone #
   
Primary contact/responsible party
Name
Relationship
Address
 
City
State
Zip
Home Phone #
Work Phone #
Cell Phone #
   
Other family member/responsible party
Name
Relationship
Address
 
City
State
Zip
Home Phone #
Work Phone #
Cell Phone #
   
Financial Information  
Medicare #
Medicare Part B?
Medicaid #
County
Other Insurance
Other Health Insurance
Long Term Care Insurance
   
Bank Accounts  
Bank #1 Name
Checking $
Savings $
Bank #2

Name
Checking $
Savings $

   
Assets  
Investments
Real Estate
Other Assets
Life Insurance?
With Whom
   
Monthly Income  
Social Security $
Pension $
Veterans Benefits $
Other $
Outstanding Debts $
   
Person Managing Applicant's Funds
Name
Relationship
Address
 
City
State
Zip
Home Phone #
Work Phone #
Power of Attorney?
   
Attestation: According to the best of my knowledge and belief, the above information is accurate and true in all respects.
Signature of Applicant
By writing your name you hereby agree to the above Attestation
Date
   
Signature of Applicant
By writing your name you hereby agree to the above Attestation
Date