Admissions Application

Please Follow The Instructions Carefully

Below is the Online Application for Admission to Kramm Healthcare and Rehabilitation (Milton, PA) and Kramm Nursing Home and Rehabilitation (Watsontown, PA). Please make sure that you fill out each section carefully and review the apllication before submitting.

After submitting, you will be directed to a page that will review all of the information that you submitted. If any of the information is incorrect, simply press the "edit" button on the Application Review page.

Please allow (1) One Hour to complete this application.

You will need:

  • Forms of Identification
  • Insurance Cards
  • Insurance Policies/Statements
  • Emergency Phone Numbers
  • Bank Account Statements
  • IRA/Retirement Statements
  • List of Medical Conditions
  • Burial Fund Information

First, which facility are you applying for admission to?

- 245 East Eighth Street - Watsontown, PA 17777
- 743 Mahoning Street - Milton, PA 17847

General Self and Family Information
Name of Applicant:
Sex:



Address:
City:
County:
State:
Zip:
Phone:
Email:
Birthdate:
Birthplace:
Previous Occupation:
Veteran?:



Veteran's Widow?:



Marital Status:






Date of Annivarsary:
Name of Spouse:
If Deceased, Date of Death:
Address of Spouse, if living:  
--------Address:
--------City:
--------State:
--------Zip:
--------Phone:
Is Spouse Currently Employed?



Address of Employer:  
-------Address:
-------City:
-------State:
-------Zip:
-------Phone:
List Children, Nearest Relatives or Responsible Persons:

Please give name, address and phone numbers

1.

2.

3.

Do you have a Power Of Attorney (POA)? (Please provide a copy during interview)



Do You have a Legal Guardian? (Please provide a copy during interview)




Name of Attorney-In-Fact designated in POA or Guardian:
Religious Affiliation
Affiliation (i.e. Baptiist, Catholic, Luthern, Protestant, etc...)
Pastor's/Father's Name:
Church Name:
Church Address:
Family Physician
Family Physician's Name:
Address:
Phone Number:
Hospital Preference:
Funeral Director:
--------Address
--------Phone Number
Personal Identifiable/Insurance Information
Social Security Number:
Medicare Number:
Blue Cross Identification Number:
Blue Cross Plan Number:
Blue Cross Group Number:
65 Special?



Security 65 Plan (Check one)





Blue Shield?:



Please Provide a copy of all insurance cards at the time of admission.
Other Hospitalization, Health Care, or Nursing Home Insurance
Company Name:
--------Address:
--------Contract/Agreement Number
Company Name:
--------Address:
--------Contract/Agreement Number
Have you assigned your Medicare rights to a healthcare insurance provider?



If yes, list name of provider:
Current Medical Conditions
List any medical conditions
Former Hospitalization
Name of Hospital:
Date:
Former Nursing Home Stay
Name of Facility:
From/To
Financial Information
Assets Self Joint
Fair Market Value of Real Estate Owned:
Balance in all Checking Accounts:
Balance in all Savings Accounts:
Balance of Cash if in excess of $500:
Cash Surrender Value of All Insurance Policies:
Value of All Corporate Stocks and Securities:
Value of all Private and Governmental Bonds:
Value of Other Assets in Excess of $500 per Asset:
Total:
Monthly Income: Self Joint
All Savings Accounts/Money Market Assets:
All Checking Accounts:
All Certificates of Deposit:
Trusts:
Social Securiy Benefits:
Pension:
Dividends:
Other Sources of Income (Rental, part-time employemt, etc...)
Total:
Burial Fund
Value of Prepaid Funeral Expenses Prepaid with whom?
Value of Prepaid amount for Self
Value of Prepaid amount for Joint
Total:
  
Have you transfered any property or assests within the last 36 months?



Electronic Signature
By typing in your name below your are electronically signing your name:
Signature: Date:
Please Complete Below if this application is prepared by other than applicant:
Name:
Relationship:
Address:
City:
State:
Zip:
Phone Number:
Email:
Date
Please review this application carefully, make any necessary changes than submit your application.

 

 

 

 

 

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