Apply for Rehabilitiaton or Short-Term Admission | Rochester NY nursing home and rehabilitation services

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Name

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Yes

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Responsible Person(s) to Notify

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Power of Attorney

Health Care Proxy

Others to Notify 1 (Click to Expand)

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Power of Attorney

Health Care Proxy

Others to Notify 2 (Click to Expand)

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Power of Attorney

Health Care Proxy

Legal Counsel

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Surgery Information

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To Maplewood Nursing Home, Inc.

In consideration of the admission of the above named person, I certify that I have knowledge of the above named individual’s assets and control or authority with respect to the same. I agree to make prompt payment in advance of nursing home charges as billed.
I understand that this agreement is intended for a short term or “Respite” stay and that the maximum length of stay at Maplewood will be 42 days in duration.

I understand that in the event my insurance does not cover my stay at Maplewood Nursing Home that I am responsible for charges incurred.
(We recommend that individuals check with their medical insurance carrier to obtain rules for coverage in a skilled nursing facility)

Signed:

Date: