The following application requests admission to Effingham Care and Rehabilitation Center Question Title * Please answer the below questions. Name Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Phone Number Question Title * Age Question Title * Date of Birth Question Title * Sex Male Female I prefer not to answer Question Title * Place of Birth Question Title * Who is the primary care physician? Question Title * Health Status of Applicant Question Title * Primary Contact Name Relationship Address City/Town State/Province ZIP/Postal Code Phone Number Question Title * Secondary Contact Name Relationship Address City/Town State/Province ZIP/Postal Code Phone Number Question Title * Additional Contact Name Relationship Address City/Town State/Province ZIP/Postal Code Phone Number Question Title * Does applicant have the following Medicare Medicaid Medicare Advantage Plan Question Title * If you have a Medicare Advantage Plan, which do you have? Question Title * Has the applicant ever been charged with a sex offense? Yes No Question Title * Does applicant use tobacco products? Yes No Question Title * Does the applicant smoke? Yes No Question Title * Person providing information for applicant Name Email Address Phone Number Question Title * 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 ccadmissions@effinghamhospital.orgThank you. Date submitted to facility Date Done
