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Nursing Home Application Form Template

Streamline Your Nursing Home Admission Process with Ease

Completing a nursing home application can feel overwhelming, especially during a stressful time. This nursing home application form template helps you efficiently gather essential information from prospective residents, ensuring a smooth admission process. You'll benefit from clear organization of necessary details, a user-friendly design that enhances completion rates, and the ability to collect data in a compliant manner, making it easier for families and facilities alike. Experience a simpler way to manage your admissions with our live template.

Use this Template (FREE) Live Preview
Applicant full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary language
Residential address
Applicant email
Applicant phone number
Current living situation
Own home
With family/caregiver
Assisted living
Hospital
Rehabilitation facility
Prefer not to say
Other
Please Specify:
Primary emergency contact full name
Relationship to applicant
Emergency contact phone number
Emergency contact email
Legal representative or power of attorney (POA) full name (if any)
Primary care physician name
Primary care physician phone
Requested care level
Skilled nursing
Assisted living
Memory care
Respite care (short-term)
Hospice/palliative coordination
Not sure
Areas where assistance is needed
Memory or cognition concerns
None
Mild impairment
Moderate impairment
Severe impairment
Not sure
Current medications (list names and doses if known)
Allergies and dietary needs
Major medical conditions or diagnoses
Advance directive or living will in place
Yes
No
Not sure
Primary insurance coverage
Medicare
Medicaid
Private insurance
Veterans benefits
Self-pay
Not sure
Other
Please Specify:
Insurance member or ID number
Responsible party for payment
Applicant
Family member
Legal guardian/POA
Insurance
Not sure
Other
Please Specify:
Preferred room type
Private
Semi-private
Either/No preference
Preferred move-in timeframe
As soon as possible
Within 2 weeks
2-4 weeks
1-3 months
3+ months
Not sure
Would you like to schedule a facility tour
Yes
No
Additional comments or questions
Legal and medical documents available to provide
Power of Attorney
Guardianship order
Advance directive/Living will
DNR order
Insurance cards
Medication list
Photo ID
None
Other
Please Specify:
I consent to the facility contacting me using the details provided for application processing
Yes
No
Signer full name (applicant or legal representative)
Relationship to applicant (if not the applicant)
Signature date
I confirm the information provided is accurate to the best of my knowledge
Yes
No
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Paper art illustration depicting a nursing home application form for FormCreatorAI article

When to use this form

Use this form when you need to collect complete intake details for a prospective resident, including contacts, medical history, medications, insurance, and decision-maker info. It helps you assess fit, set care levels, and plan a safe move-in date. It is ideal during a hospital discharge to long-term care, when a family caregiver can no longer meet needs, or when you compare facilities before choosing. To shape care goals and staffing, pair the application with the Nursing care plan form. For diet needs or allergies, reference the Nutrition care plan form. If the resident is transferring from home health services, include the Home health certification and plan of care form to maintain continuity.

Must Ask Nursing Home Application Questions

  1. Who is the resident's legal representative and primary contact, and how can we reach them?

    This identifies who can consent, make decisions, and provide accurate history. If a private caregiver will continue supporting the resident, the Home care aide registration form helps you onboard them properly.

  2. What assistance does the resident need with daily activities (mobility, bathing, dressing, toileting, eating, cognition)?

    Clear ADL needs guide room selection, equipment, and staffing levels from day one. If end-of-life support is expected, the Hospice care checklist form can clarify goals and comfort measures.

  3. What diagnoses, medications, allergies, and infection risks should we know about?

    These details reduce medication errors and help you follow safety protocols. They also inform diet, therapy, and monitoring plans.

  4. What insurance plans and payment sources will cover care?

    Knowing coverage up front speeds verification and prevents billing delays. It also helps you set the correct payer, authorizations, and deposit needs before admission.

  5. Who currently provides care, and has the resident had recent hospital or rehab stays?

    Current providers and recent discharges reveal active orders, mobility status, and follow-ups you must continue. Request discharge summaries and contact info so your team can coordinate a smooth transition.

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