Marquette County Medical Care Facility

Admission Application

Thank you for choosing Marquette County Medical Care Facility for the potential placement of yourself or a loved one. We understand that this is a time of change and would like to help.

We would like to explain the process of admission to a long-term facility. The attached enclosures serve two purposes. One purpose is to inform you of the necessary paperwork, which must be provided by you or your doctor. The medical information provided by your doctor updates MCMCF on the past and present health status, current medications and current lab values and x-rays. The medical information needs to be completed and returned prior to the actual admission date. Mandatory information that must be provided by you or the family include a copy of Medicare, Medicaid, Social Security and supplemental insurance cards. We also need a copy of power of attorney or guardianship papers. Medications are
provided by a pharmacy contracted by MCMCF. If the potential resident is being admitted from home we would also like you to bring the bottles of medications here for review. This provides the nursing staff with valuable information regarding what the individual has been receiving. These medications will be returned to you.

The second enclosure, titled pre-admission application, requests more comprehensive information of a personal nature. We encourage you to complete the document for continuity of care. It provides important insight into life events, which have occurred. It enables the staff to anticipate needs and promote the highest quality of life attainable. In addition, these questions will be asked during the admission process. If we can obtain this information prior to arrival, the actual admitting process/paperwork will proceed faster for you.

To summarize, the information we have requested assists us to better understand you or your loved one. We take pride in promoting the highest quality of life attainable for the resident’s entrusted in our care. We understand that this transition period can be a difficult time. We would like to make the adjustment period proceed as smoothly as possible. If you have any questions or need guidance or assistance please call.

INFORMATION NEEDED FOR POTENTIAL ADMISSION TO MCMCF

  • A history and physical from your doctor (the history and physical must be dated within five days of arrival to the facility. We will contact your physician for an update if the time frame is exceeded).
  • A chest x-ray (taken less than 90 days from the date of admission)
  • Lab work: Electrolytes, BUN, creatinine, glucose and CBC.
  • Mental health screening forms DCH-3877 and DCH-3878 (MANDATORY)
  • A list of all the current medications and dosages, both prescriptions, over the counter medications and herbs/vitamins. (MANDATORY)
  • MCMCF maintains a no-smoking policy. Please discuss a smoking cessation program with your physician prior to placement.
  • Identify the source of payment: provide copies of Medicare, Medicaid and supplemental insurance cards. If this information is not provided, the resident’s family will be responsible for payment of monthly charges. We can not bill your insurance without cards.
  • A copy of the Social Security card.
  • A copy of power of attorney or guardianship papers.
  • A copy of ADVANCE DIRECTIVES (if available)

PRE-ADMISSION APPLICATION

Directions: Please fill out this form completely and return. Some questions may not apply to your loved one however to provide optimum care it is imperative that we know as much as possible about this person.