Applicant's name	__________________________	Address	__________________________
Birth date	__________________________		__________________________
			__________________________
Social Security #	__________________________	Phone	__________________________
Medicare #	__________________________	Medicaid#	__________________________
Insurance	__________________________	Policy #	__________________________
Primary Care Physician__________________________________________________________
Have you had a hospital stay recently?    Yes_________    No__________
Where__________________________ Admit Date____________ Discharge Date____________
Primary Diagnosis__________________________________________________________
Medical History:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Have you ever been admitted to a Skilled Nursing Facility before?    Yes_________    No__________
Have you ever been admitted to a Assisted Living Facility before?    Yes_________    No__________
Where__________________________ Admit Date____________ Discharge Date___________
Admitting Diagnosis__________________________________________________________
Family member/Responsible party (Health care proxy/P.O.A.)		Family member/Responsible party (Health care proxy/P.O.A.)
Name	__________________________	Name	__________________________
Address	__________________________	Address	__________________________
	__________________________		__________________________
Home phone	__________________________	Home phone	__________________________
Work phone	__________________________	Work phone	__________________________
FINANCIAL INFORMATION
Income		Assets
Social security	__________________________	Checking account	__________________________
Pension	__________________________	Savings account	__________________________
Other	__________________________	Real Estate value	__________________________
		CD's, Stocks, Bonds, IRA's	__________________________
		Other	__________________________
Has there been any transfer of assets out of your name whithin the past 36 months?   Yes_________   No__________
Explain.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
To the best of my knowledge, all of the information on this application is truthful and accurate as of this date. The signing of this application allows the release of medical information on behalf of the applicant. Sugar Hill guarantees the confidentiality of all the information on this application.
_______________________________________		_______________________________________
Applicant's signature		Date
_______________________________________		_______________________________________
Family member/Responsible party		Date