Apply For Admission – Atlantic Shores Rehabilitation and Healthcare Center

Demographic Information

Resident Name:(Required)

Social Security #(Required)

Primary Payer:(Required)

Long Term or Short Term? If Short Term, estimated Length of Stay:(Required)

Marital Status (M/S/W/D)(Required)

Spouse’s Social Security #

Financial Responsible Party:(Required)

Relationship:(Required)

Correct Mailing Address for Billing Statements:(Required)

Email address of FRP:(Required)

Phone # of FRP:(Required)

Social Security $(Required)

Dividends and Interest $

Dividends and Interest $ Type:

Income from Annuities $

Income from Annuities $ Type

Rent from Real Property $

Rent from Real Property $ Type

Assets

List all current bank accounts (Including but not limited to checking, savings, CD’s, Money Markets, etc.) 60 months statements required for all accounts, including those closed in the last 60 months.

Name of Bank (Primary):(Required)

Type of Account:(Required)

Account Owner(s)(Required)

Current Account Balance:(Required)

Name of Bank (Secondary):

Current Account Balance:

Name of Bank (Third):

Current Account Balance:

If yes, please describe where assets were transferred:

Investments/Retirement Accounts

List all investment/retirement accounts (including but not limited to stocks, bonds, mutual funds, etc.)

Name of Investment/Brokerage Company (Primary):

Name of Investment/Brokerage Company (Secondary):

Current, Appraised or Estimated Value $

Name of Insurance Company:

Cash Surrender Value:

Name of Insurance Company:

If yes, please describe where assets were transferred:

Cash Surrender Value:

Name of Funeral Home:

Please answer the following questions:

If yes, please supply the date and name or Hospital/Institution:(Required)

ID Cards: Driver’s License, Social Security Card
Proof of Citizenship: Birth Certificate or US Passport
All Insurance Cards: Medicare, Medicaid/Public Assistance, other Health Insurance
Current Income Verification for all sources
Bank Statements: 12 months for all accounts
Current Investment/Retirement Account Statements
Copy of Deed, property taxes, appraisal…
Auto registrations
Proof of all Health Insurance Premiums
Proof of all Life Insurance policies
If Married: marriage license, monthly expenses for spousal allocation, and all of the above for the community spouse

Upload Documents

Max. file size: 5 MB.

Completed by:(Required)

Name

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Name

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Admission Application

Click Here for the Downloadable Admission Application & Financial Questionnaire

Demographic Information

Income

Assets

Investments/Retirement Accounts

Real Property

Life Insurance

Burial Accounts

Automobiles

Please answer the following questions:

Documents Needed:

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