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FACILITY INTAKE FORM

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Please fill out the attached form and FAX to 617-969-2406 our executive assistant will be in touch with you within 48 hours.  If you have any questions or concerns please don't hesitate to call 617-969-2205 extension 205 for Ashley McCormack.

 

 

 

 

Facility Information
Facility Name
Facility Address
Administrator
Telephone #
Fax #

Applicant Background
Name
Admit Date
Gender Male Female
Marital Status Single    Married    Divorced    Widowed
Social Security #
Date of Birth mm/dd/yy
Is applicant competent to assist? Yes No
Current Payment Status
Estimated Medicaid Start Date

Responsible Party
Name
Relation
Address
Phone
Home *
Work
Cell
E-mail
(Please Include)


Please select one:

Private Pay

Facility Pay


Has medicaid application been made before?
Yes
No
If yes:
When      Where
Status of prior application?

Note: Please note any difficulty that we should be aware of.


Please enter the following text: