Admission Forms Checklist

Resident: , Date of Admission:

I/We have received and reviewed information on the policies and procedures of Daughters of Israel and have signed the following forms required for admission. Please return completed forms to the Social Services Department.

I/We have signed and returned the following forms:

Agreement for Admission
Resident’s Family Contact Information
Request for Direct Deposit (Social Security)
Authorization and Agreement for Direct Deposit (Social Security)
Assignment of Benefits
Financial Worksheet and Authorization to Release Financial Information
Jewish Genealogy
Authorization to Use and Disclose Protected Health Information
Resident’s Bill of Rights Acknowledgement
Informed Consent for Resuscitative Status
Influenza Immunization Informed Consent
Pneumococcal Immunization Informed Consent
Need for Hospitalization
Prescription and Responsible Party Billing Authorization
Beauty Parlor and Barber Shop Services
Publicity Permission
Personal Needs Account
Sub-Acute rehabilitation Discharge Form
Extra Charge and Explanation Form
Dental Consent
Family Council Consen

I/We have received the following information:

Advance Directives for Health Care
Things to Know About Daily Life Handbook (a guide about the services provided and the policies and procedures followed at Daughters of Israel including the Resident’s Bill of Rights and Notice of Privacy Practices)
What You Should Know About Pain Management Brochure
Evercare Information Brochure

Signature of Resident		Date
Signature of Responsible Representative		Date
Social Worker

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Phone: 973-731-5100 • Fax: 973-736-7698
www.doigc.org
1155 Pleasant Valley Way, West Orange, NJ, 07052