APPENDIX C GUARDIANSHIP REFERRAL WORKSHEET ☐ Guardianship of the Person ☐ Guardianship of the Property Referral Source:
Patient name:
Pronouns:
Title:
Department/Unit:
Telephone:
Email:
Other information:
Patient Information Full Name: Gender: Marital Status: Telephone: Street Address: City, State, Zip: Current Location: Language: Communication preferences/ accommodations:
DOB:
Pronouns:
☐ Male ☐ Female ☐ Other:
Race: Email:
Other: ☐
English ☐
Yes ☐ Unsure ☐ ☐
No
Financial Power of Attorney?
Advance directive?
Yes No ☐ ☐ Unsure ☐
Pre-admission living arrangements (type of housing, address, list of individual residing with the patient, if any, and their contact information):
Brief description of medical/mental health condition and its impact on the patient's ability to make personal or financial decisions:
Insurance & Government Benefits/Services Insurance coverage: Medical Assistance:
MA recipient MA/LTC application has been made ☐ ☐ Social Security Administration (SSA) beneficiary (SSI/SSDI) U.S. Department of Veterans Affairs (VA) beneficiary ☐ ☐ Developmental Disabilities Administration (DDA) services recipient ☐
Benefits:
Other: ☐
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Attach any insurance information and other relevant records.
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