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Please answer the below questions.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Age

Date of Birth

Sex

Male

Female

I prefer not to answer

Place of Birth

Who is the primary care physician?(Required.)

Health Status of Applicant(Required.)

Primary Contact

Name

Relationship

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Secondary Contact

Name

Relationship

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Additional Contact

Name

Relationship

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Does applicant have the following

Medicare

Medicaid

Medicare Advantage Plan

If you have a Medicare Advantage Plan, which do you have?

Has the applicant ever been charged with a sex offense?

Yes

No

Does applicant use tobacco products?

Yes

No

Does the applicant smoke?

Yes

No

Person providing information for applicant

Name

Email Address

Phone Number

Effingham Care and Rehabilitation Center is a tobacco free facility.

If any of the statements above have been falsified, the applicant is subject to removal from the facility without recourse.

Should you have any questions or need assistance, please do not hesitate to contact Admissions at (912)754-1080 or email us at communityadmissions@effinghamhospital.org

Thank you.

Date submitted to facility

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

The following application requests admission to Effingham Care and Rehabilitation Center