Teresian House Center for the Elderly 200 Washington Avenue Extension Albany, New York 12203-5394 Phone: 518- 456-2000 Fax: 518-724-2796 Reservation Date: MM slash DD slash YYYY Date of Admission: MM slash DD slash YYYY Admission No. Room No. Name First Middle Address Street Address City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneAddress Street Address Date MM slash DD slash YYYY AgeCitizen? Yes No Hospital Preference Father’s Name Mother’s Maiden Name MARITAL STATUS: Single Married Divorced Separated Widowed Spouse: First If living: Street Address If deceased: MM slash DD slash YYYY Social Security # Medicaid # Veteran’s # Medicare # Part A? Yes No Part B? Yes No Medicare Part D Plan?: Yes No (Name of Plan): Other Hospital Insurance Please attach 1 copy (front&back) of Social Security, Medicare, Health Insurance & Prescription cards.Max. file size: 50 MB.HEALTH CARE AGENT MUST BE LISTED AS FIRST CONTACT FOR EMERGENCIES AND HEALTH CARE DECISIONS (if one designated) When we are successful in reaching one person on the contact list we will not make any further calls, it will be the responsibility of the person contacted to call other family members. Please prioritize the order for contacts. (Additional contacts should be listed on a separate page and attached) ListNameAddressRelationshipHome TelephoneWork Telephone Add RemoveListAttorneyAddressHome TelephoneWork TelephoneBURIAL ARRANGEMENTS:Person responsible for burial arrangements: TelephoneFuneral Director: Telephone NumberName: WORK HISTORY:Former occupation Date Retired MM slash DD slash YYYY Last place of employment FINANCIAL: (monthly)Social Security Benefits ($)Railroad Retirement ($)Veteran’s Benefits ($)NYS Pension ($)Other Pension ($)from Whom? ( Address ) Annuity ($)from Whom? ( Address ) Other Source of Income ($)Specify Do you own real estate? Approximate value ($)Do you own investments? Approximate value ($)Has there been a transfer of funds in the past 60 months? Yes No Date MM slash DD slash YYYY Amount ($)Has a trust been established? Yes No Year establishedPlease provide a copy of the trust Name of Bank: Address Account No.Present BalanceList All Investment Accounts: Add RemovePolicy No.Cash ValueAny other Insurance:Do you have a Health Care Proxy Yes No Living Will Yes No M.O.L.S.T. Yes No If yes, please attach a copy of all documentsMax. file size: 50 MB.Do you have a Power of Attorney? Yes No If yes, please attach a copyMax. file size: 50 MB.Power of Attorney held by: Address To whom should bills be sent? Address To whom should business mail be sent? Address To whom should personal mail be sent? Address To whom should personal mail be sent? Office telephoneHave you ever applied/been admitted to/ or denied admission by any other Institution or Home? Name of Home: Date MM slash DD slash YYYY It is the policy of Teresian House that all available services are provided without regard to age, sex, race, color, ancestry, national origin, religious creed, handicap, or disability, sponsor, or sexual preference.Date of Application MM slash DD slash YYYY Signature Responsible Person Referred by CommentsThis field is for validation purposes and should be left unchanged.
