Wayne County, NY · Wayne County
Nursing Home Admission Application
This universal application and financial form is for people seeking admission to one or more nursing homes in Wayne County.
At a glance
- Issued by
- City of Wayne County · Wayne County, Wayne County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- waynecountyny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use this application to provide information for nursing home admission and indicate which Wayne County homes you are interested in. It asks about the applicant’s identity, contacts, insurance, burial and clergy information, finances, real estate, and business interests. The form also includes Medicare payer questions and says copies of all insurance cards must be provided at admission.
Who needs it
An applicant or responsible party seeking admission to one or more of the nursing homes listed on the form should complete it.
How to submit it
The form lists Blossom View, Newark Manor, DeMay Living Center, and Wayne County Nursing Home, with each facility’s address, telephone number, fax number, and email or website information.
About notarization
This application is signed without a notary; the applicant and responsible party sign and date it, and the form does not specify a notarized attachment or step.
How to submit this form
- 1
Download the Application
Download the Nursing Home Admission Application PDF.
- 2
Complete the Applicant Sections
Provide the requested identifying, contact, insurance, burial and clergy, and financial information.
- 3
Gather Insurance Cards
The form says copies of all insurance cards must be provided at the time of admission.
- 4
Contact a Listed Facility
Use the address or contact information listed on the form for the nursing home you are interested in.
Frequently asked questions
- Do I need a notary for the Nursing Home Admission Application?
- No. The application has signature and date lines for the applicant and responsible party, but no notary block or notarized attachment is specified.
- How do I submit the Nursing Home Admission Application?
- The form lists contact details for Blossom View, Newark Manor, DeMay Living Center, and Wayne County Nursing Home. Contact the facility you are interested in using the information on the form.
- What information does the application ask for?
- It asks for identifying and contact details, insurance information, financial information, real estate and business interests, and burial and clergy information.
- Which nursing homes are listed on the application?
- The application lists Blossom View, Newark Manor, DeMay Living Center, and Wayne County Nursing Home.