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Application for Residency

Countryside Christian Community

200 Bellann Court, Annville, PA 17003-9012

717-867-4636

Note: This application must be completed in its entirety to be considered for residency or a waiting list.  No information included herein will be shared with other individuals or parties not necessary for the processing of your application to the community.

Today’s Date:_______________For office use only:

Application is for: (Check only one)Application received______________Admission policy & disclosure provided:

Nursing care________________Approved for admission___________Initials:Date:

Personal Care_______________Date of arrival_______________________________   ___________

Respite Care________________Admitted from___________________

Cottage/apartment___________Contact start date____________________________   ___________

Applicant’s Name:

Last________________________ First___________________ Middle___________________ Maiden___________________

Marital Status: (Circle one)SingleMarriedWidow/WidowerDivorcedCo-habitant

If admission is desired for you and a co-applicant, indicate name of co-applicant: __________________________________

Current Address:

Street____________________________________________________Town_____________________________________

State__________ Zip __________________ Telephone Number (          )_____________  E-mail:____________________

Your present age______ Birth date_____________________    Birthplace_________________________________________

Social Security Number__________________________ Former Occupation________________________________________

Medicare Number__________________________________  (If applicable, Medicaid #): ___________________________

Secondary Insurance to Medicare (Co-insurance) __________________________________________________________

Group Number _________________________________________ Identification Number ___________________________

Type of plan if known: (HMO, PPO, PPS, std. plan, etc.): _____________________________________________________

Long-term care insurance carrier ___________________________________ Identification Number ____________________

Coverage included: (Skilled nursing, personal care, etc.): _____________________________________________________

Father’s Name ____________________________________ Mother’s Name ____________________________________

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