Application for Residency

Name of potential resident(Required)

First Name Last Name

How did you hear about Broadview?

Applicant is currently at(Required)

Home

Hospital

Nursing Home/Rehab

Name facility current facility (if applicable)

Phone Number of current Facility

General Information

Social Security #

Date of birth

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Cell or landline(Required)

Cell

Landline

Email(Required)

Enter Email Confirm Email

How long has the applicant been at this address?(Required)

Does the applicant rent or own?(Required)

Rent

Own

Other

Birthplace(Required)

Primary Language(Required)

Make and year of automobile

Previous Occupation(Required)

Emergency Contact Information

Contact Person #1

Contact Name(Required)

First Name Last Name

Relationship to applicant(Required)

Contact address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Cell or landline(Required)

Cell

Landline

Secondary Phone Number

Cell or landline

Cell

Landline

Contact email(Required)

Contact Person #2

Contact Name(Required)

First Name Last Name

Relationship to applicant(Required)

Contact address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Cell or landline(Required)

Cell

Landline

Secondary Phone Number

Cell or landline

Cell

Landline

Contact email(Required)

Insurance Information

Medicare number(Required)

Supplemental Insurance(Required)

Yes

Supplemental Insurance policy number?(Required)

Name of supplemental Insurance(Required)

Address of supplemental Insurance(Required)

Street Address Address Line 2 City State ZIP Code

Phone number of supplemental Insurance(Required)

Supplemental Insurance I.D. Number(Required)

Insurance Cards & ID

Provide copies of all insurance cards front and back, along with Medicare card and license or picture I.D.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Advance Directives

Do you have a Health Care Proxy?(Required)

Yes

Name of Health Care Proxy(Required)

First Name Last Name

Relationship of Health Care Proxy(Required)

Address of Health Care Proxy(Required)

Street Address Address Line 2 City State ZIP Code

Primary phone number of Health Care Proxy(Required)

Cell or landline(Required)

Cell

Landline

Secondary phone number of Health Care Proxy

Cell or landline

Cell

Landline

Email of Health Care Proxy(Required)

Enter Email Confirm Email

Do you have a letter invoking health care proxy(Required)

Yes

Do you have a Massachusetts Comfort Care Form (Do Not Resuscitate)?(Required)

Yes

Do you have a MOLST form?” (Medical orders for life sustaining treatment)(Required)

Yes

Durable Power of Attorney (DPA)(Required)

Check all that apply.

DPA for both healthcare and finances

DPA for just healthcare

DPA for just finances

I do not have anyone with Durable Power of Attorney

Name of Individual with Durable Power of Attorney for Healthcare & Finances (both)(Required)

First Last

Relationship of Individual with Durable Power of Attorney for Healthcare & Finances (both)(Required)

Address of an Individual with Durable Power of Attorney for Healthcare & Finances (both)(Required)

Street Address Address Line 2 City State ZIP Code

Primary phone number Healthcare & Finances DPA(Required)

Cell or landline(Required)

Cell

Landline

Secondary phone number Healthcare & Finances DPA

Cell or landline

Cell

Landline

Email For Healthcare & Finances DPA(Required)

Name of Durable Power of Attorney for Healthcare(Required)

First Last

Relationship of Durable Power of Attorney for Healthcare(Required)

Address of Durable Power of Attorney for Healthcare(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone of Durable Power of Attorney for Healthcare(Required)

Cell or Landline(Required)

Cell

Landline

Secondary Phone of Durable Power of Attorney for Healthcare

Cell or Landline

Cell

Landline

Email of Durable Power of Attorney for Healthcare(Required)

Enter Email Confirm Email

Name of individual with only Durable Power of Attorney for Finances?(Required)

First Last

Relationship of individual with only Durable Power of Attorney for Finances?(Required)

Address of individual with only Durable Power of Attorney for Finances(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone of individual with only Durable Power of Attorney for Finances(Required)

Cell or Landline(Required)

Yes

Secondary Phone of individual with only Durable Power of Attorney for Finances

Cell or Landline

Yes

Email of individual with only Durable Power of Attorney for Finances?(Required)

Enter Email Confirm Email

Please upload any advance directive documents

Drop files here or

Accepted file types: pdf, Max. file size: 64 MB.

Medical Information

Primary Care Physician Name(Required)

Prefix First Last

Primary Care Physician Phone(Required)

Hospital Preference(Required)

Hospital Preference Phone(Required)

Dentist Name

Prefix First Last

Dentist Phone

Podiatrist Name

Prefix First Last

Podiatrist Phone

Optometrist Name

Prefix First Last

Optometrist Phone

Psychiatrist Name

Prefix First Last

Psychiatrist Phone

Funeral Home

Funeral Home Phone

How often do you presently see your doctor?

Do you see a medical specialist?(Required)

Yes

Why do you see a medical specialist:(Required)

Name of specialist(Required)

Prefix First Last

What is their specialty?(Required)

What is the Diagnosis?(Required)

How would you describe your present state of health?(Required)

Do you have a health condition that requires regular, daily attention or monitoring?(Required)

Do you require assistance to administer your medication?(Required)

Yes

Please list medications

Do you have any allergies to medication, food or environment allergies?(Required)

Yes

Please list allergies

Tasks

Fire Awareness(Required)

Independent

Needs Assistance

Complete Assistance

Budgeting/check writing(Required)

Independent

Needs Assistance

Complete Assistance

Transportation(Required)

Independent

Needs Assistance

Complete Assistance

Personal Hygiene(Required)

Independent

Needs Assistance

Complete Assistance

Dressing(Required)

Independent

Needs Assistance

Complete Assistance

Bathing(Required)

Independent

Needs Assistance

Complete Assistance

Walking(Required)

Independent

Needs Assistance

Complete Assistance

Taking Medications(Required)

Independent

Needs Assistance

Complete Assistance

Toileting(Required)

Independent

Needs Assistance

Complete Assistance

Is their any information about any of the tasks you would like to share?

Confidential Financial Statement

Printed Resident Name(Required)

Prefix First Middle Last Suffix

This Financial Statement is given to the Administrator prior to admission. Be assured that the information is held in the strictest confidence. Broadview, Inc. is a private pay facility. To protect all concerned, it’s necessary that you provide Broadview, Inc. with a financial statement that shows the potential resident is financially capable of maintaining residency at Broadview.

Section A Worksheet to the document prospective resident’s assets.

Monthly Income

Social Security Payments(Required)

Social Security Diability(Required)

Pension Payments(Required)

Veteran's Benefits(Required)

Interest Income(Required)

Investment Income(Required)

Rental Income(Required)

Support From Family(Required)

Other Monthly Income(Required)

Monthly Income Total

The monthly income entries are automatically totaled.

Assets & Accounts

Bonds(Required)

Stocks(Required)

Mutual & Money Market Funds(Required)

Savings(Required)

Life Insurance (Cash Value)(Required)

Property(Required)

Other(Required)

Assets & Accounts Total

This field is calculated based on the asset & accounts entries.

Do you have Long-Term Care Insurance?(Required)

Yes

Insurance Company(Required)

Policy number(Required)

Telephone Number(Required)

Supporting Financial Documentation

Please upload documentation supporting financials of affordability of at least 6 months at Broadview.

Drop files here or

Accepted file types: pdf, Max. file size: 64 MB.

Section B

Please provide information about the person who has access to the funds should it become necessary due to mental incapacity of the resident.

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

Section C

Please provide the name of the person that will accept responsibility for meeting monthly payment obligations if it is other than the resident themselves.

Name

First Last

Relationship

Phone

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Section D

I understand and agree that the foregoing application is not a contract or reservation for residence. Nothing contained herein is binding on either party until all parties have signed a Residency Agreement, I certify that the information that I have provided in this application is true and correct. I understand that if there comes a time that the Directors of Broadview feel that we are unable to provide you with the care necessary for your optimal well-being, we reserve the right to request that you transfer to a more appropriate facility, which would better suit your needs.

Name of person submitting this application(Required)

Prefix First Middle Last Suffix

Email of person submitting this application(Required)

Enter Email Confirm Email

I certify that the information that I have provided in this application is true and correct.(Required)

Yes