Family Owned
Call: 585-786-8151

62 Prospect Street
Warsaw, New York 14569

Admission Application

Below is the information that East Side Nursing and Rehabilitation Center will need in order to begin the screening process for admission.

  • Admission Application
  • Financial information form
  • Medical information from the Patient’s Primary Care Provider or facility where is presently admitted
  • Power of Attorney forms, signed.
  • Health Care Proxy if designated
  • Copy of all Insurance cards (Medicare, Secondary Insurance, Prescription Plans)

* The above information must include:

 

*Coming from home

  • Doctors visits for the last 4 months
  • Medication list
  • Reports from Labs/Culture reports
  • Reports from X-rays / Scans etc.
  • Demographic sheet/ Face Sheet
  • Immunization records
  • Immunization records
  • PRI( Patient Review Instrument)

*Coming from another facility or hospital

  • Admission History and Physical reports
  • MD notes and orders
  • Physical therapy evaluations and updates
  • Occupational therapy evaluations and updates
  • Reports from Lab work/ X-rays/ Scan
  • Operative reports if applicable
  • Medication list
  • Demographic sheet/Face Sheet
  • PRI( Patient Review Instrument)

After reviewing the above information, if anything further is required we will notify you or the facility as soon as possible. If you have any further question, please do not hesitate to contact us at 585-786-8151.

Thank you in advance for your assistance.

Amy Steen 
Admissions Coordinator

Admission Application

Please fill out the following information to the best of your knowledge. East Side Nursing and Rehabilitation Center will need this application returned for the admission process. Any question or concerns please feel free to contact the admissions office at 585-786-8151. Thank you for your time!

Please send in a copy of the following information if you have this in place

If Yes,

Has he/ she gone to see a specialist in the past few years such as: Please list dates

Per New York State regulations, it is necessary to inquire regarding Funeral Home Arrangements: Please indicate below:

If organ donor, name of receiving facility and phone number:(Please send in a copy of the paperwork for organ donation)

If there is any additional information that you would be able to provide, please feel free to share the information with us, as our goal is to provide as smooth and pleasant a transition as possible from your home to ours. Thank you for your cooperation and understanding.

FEDERAL AND STATE LAWS PROHIBIT DISCRIMINATION IN ANY FORM ON THE BASIS OF RACE, CREED, COLOR, NATIONAL ORIGIN, SEX, AGE, DISABILITY, HANDICAP, BLINDNESS, MARITAL STATUS, SEXUAL PREFERENCE, SPONSOR OR SOURCE OF PAYMENT IN THE ADMISSION, RENTENTION AND CARE OF RESIDENTS.

Attached is the financial information that needs to be completed. Even if you are applying for Medicaid, please be sure this information is filled out. If you have any questions or concerns, please feel free to contact us at 585-786-8151.

Financial Information

Other Insurance:

Income

Monthly Amount:

Total Value:

I certify that all information given is true and correct to the best of my knowledge.

Address of Representative: