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Application for Residency to Mt. Washington Care

We are committed to preserving the dignity of every person served by effectively meeting his or her medical, social, emotional, and spiritual needs.

Application For Residency

To apply for admission, please complete this questionnaire and submit it. All information will be held in confidence. A more complete medical history and physical exam will be recorded on another form. This application will become a part of the “Resident Agreement”.

First Name

Last Name

Street Address

Address Line 2

City

State

Zip

Phone Number

Email Address

Religion

Church

Marital Status

Date of Birth

Birth City

Birth State

Social Security Number

Medicare Number

Effective Date

Medicaid Number

Effective Date

Co- Insurance Name & Number

Effective Date

Funeral Home

Pre-Paid

Person Completing Form

Relationship to Resident

Phone Number

Street Address

Address Line 2

City

State

Zip

How Did You Hear of Us?

Have You Visited Another Facility?

If Yes, Which One?

Provide Overall Medical Diagnoses

Resident's Current Physician

Physician's Phone Number

Please Select All That Apply

Mentally Alert Eats Independently Ambulatory Bed Ridden Continent Forgetful Requires Help with Feeding Walks with Assistance Requires Bed Rail Incontinent Confused Requires Special Diet Chair-Ridden

Admission Date Desired

Resident Now Resides at

Reason for Seeking Admission

Name Releasing Medical Information

I agree to the release

Who is Financially Responsible (Name)

Phone Number

Street Address

Address Line 2

City

State

Zip

Has trust account been established?

If yes, please detail and a copy needed

Durable Power of Attorney appointed for financial affairs?

Has a Legal Guardian been appointed?

Has a Living Will been executed?

Has a Durable Medical Power of Attorney been appointed?

Contact Us

6900 Beechmont Avenue
Cincinnati, Ohio 45230
(513) 231-4561 (phone)
(513) 624-3728 (fax)
admissions@mtwcc.com

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