Admission & Intake Paperwork

Admission & intake

Everything a nursing home, rehab or hospital must collect and have signed before or at admission — completed here once, on a tablet, and stored with the resident's record.

Intake packet

Saved automatically on this device as you type. 0 of 14 forms signed.

Resident identity

Legal identity as it must appear on the medical record and every state form.

Legal name *Preferred nameDate of birth *Last 4 of Social Security number *Used only for identity verification and billing.Gender identityPreferred language / interpreter neededRequired by ADA and Section 504 for meaningful access.Religion or spiritual preferenceMarital statusAddress before admission

Admission details

Where the resident is coming from, why, and who is expected to pay.

Admission date *Admitted from *Reason for admission / primary diagnosis *Type of stay *Expected length of stayRoom or roommate preference

Responsible parties & contacts

Who we call first, who may make decisions, and who may receive updates in this app.

Emergency contact name *Emergency contact phone *Relationship to resident *Power of attorney / legal guardianAttach the signed POA or guardianship order.POA phoneFamily emails to invite to the portalEach person gets their own login and their own audit trail.How should we notify family of a change of condition?

Insurance & financial

Everything billing needs so coverage days and appeals can be tracked from day one.

Medicare number (MBI)Medicaid numberSecondary or Medicare Advantage planPolicy / member numberPrior authorization numberCovered days authorized at admissionDrives the benefit-day counter and the appeal countdown.Financially responsible partyVA benefits or long-term care policy

Clinical baseline

Collected at admission and used for the MDS 3.0 assessment and the baseline care plan (due within 48 hours).

Allergies and reactions *Current medications (name, dose, last taken) *All diagnoses and history *Diet order, textures, thickened liquidsMobility, transfers, fall historySkin condition / existing wounds on arrivalPhotographed and documented on day one to protect the resident and the facility.Cognition, memory, behaviors, wandering riskVision, hearing, dentures, glasses, hearing aidsInfluenza, COVID-19, pneumococcal statusOffer and documentation required by 42 CFR §483.80(d).TB screening result and date *Attending physician and phone *Preferred pharmacy

Advance directives & code status

Federal Patient Self-Determination Act requires this to be asked and documented at admission.

Code status *POLST / MOST / out-of-hospital DNR on file?Living willMedical power of attorneyOrgan donation wishesFuneral home preference

Personal, property & preferences

Person-centered care planning (42 CFR §483.21) plus the property inventory that prevents lost-item disputes.

Daily routine — wake time, bath time, nap, bedtimeFoods loved and foods refusedActivities, hobbies, music, faith servicesLife story staff should knowProperty inventory (jewelry, phone, TV, wheelchair, dentures)Signed by staff and family at admission and re-checked at discharge.Personal needs / trust fund account setup

Signature

Type the full legal name of the resident or their legal representative. It is applied to each form you sign below, with the date and time.

Required forms

Each one is required by federal rule, state licensing standards or facility policy. Sign here and the executed copy stays with the record for the length of the stay and the state's retention period.

Admission agreement & facility contract
State licensing + 42 CFR §483.15 · signed by Resident or legal representative
Services included, charges, bed-hold policy, refund policy, transfer and discharge rights. Third-party guarantees of payment are prohibited.
Awaiting signature
Resident Rights acknowledgment
42 CFR §483.10 + state residents' bill of rights · signed by Resident or representative
Given in writing, in a language the resident understands, before or at admission.
Awaiting signature
HIPAA Notice of Privacy Practices + authorization to disclose
45 CFR §164.520 / §164.508 · signed by Resident or representative
Names exactly which family members may see which sections of this portal. Nobody gets a login without it.
Awaiting signature
Advance directive acknowledgment
Patient Self-Determination Act, 42 U.S.C. §1395cc(f) · signed by Resident or representative
Asks whether a directive exists, offers to help create one, and documents the answer either way.
Awaiting signature
Consent for treatment, photography & wound documentation
State consent law · signed by Resident or representative
Includes consent to photograph wounds for the clinical record and to use telehealth.
Awaiting signature
Medicare SNF Beneficiary Notices (SNFABN / NOMNC)
42 CFR §405.1200 · signed by Resident or representative
Notice of Medicare Non-Coverage must be delivered at least 2 days before covered services end. Delivery date starts the fast-appeal clock in the Insurance section.
Awaiting signature
Arbitration agreement (voluntary)
42 CFR §483.70(n) · signed by Optional — resident or representative
Cannot be a condition of admission, must be explained in plain language, and may be rescinded within 30 days.
Awaiting signature
Assignment of benefits & financial disclosure
Medicare/Medicaid billing rules · signed by Financially responsible party
Authorizes billing of Medicare, Medicaid or the private plan and discloses applied income.
Awaiting signature
Personal property inventory
42 CFR §483.10(f)(9) · signed by Resident, family and admitting staff
Itemized at admission, countersigned, and re-verified at discharge.
Awaiting signature
Photo, media & directory listing release
HIPAA facility directory rules · signed by Resident or representative
Controls whether the resident appears in newsletters, activity photos or the facility directory.
Awaiting signature
Influenza, COVID-19 and pneumococcal vaccine consent or refusal
42 CFR §483.80(d) · signed by Resident or representative
Education must be given and the decision documented for every resident.
Awaiting signature
Preadmission Screening and Resident Review (PASRR Level I)
42 CFR §483.100–138 · signed by Referring provider + facility
Required for every Medicaid-certified facility before admission; screens for mental illness and intellectual disability.
Awaiting signature
Trust fund / personal needs allowance authorization
42 CFR §483.10(f)(10) · signed by Resident or representative
Written authorization before the facility may hold or manage resident funds; quarterly statements required.
Awaiting signature
Ombudsman, survey results and grievance contact acknowledgment
42 CFR §483.10(g)(4) · signed by Resident or representative
Confirms the family received the ombudsman number, state hotline and the last survey results.
Awaiting signature

What has to happen, and when

Before arrival: PASRR Level I, hospital records, insurance verification and prior authorization, bed offer.
Day of admission: Identity, signatures, property inventory, skin check with photos, medication reconciliation, TB screening, physician orders.
Within 24 hours: Family portal invitations sent, code status posted to every clinical screen, dietitian and therapy referrals.
Within 48 hours: Baseline care plan in place (42 CFR §483.21(a)).
Within 14 days: Full MDS 3.0 assessment and comprehensive person-centered care plan; family invited to the care conference.
Ongoing: Quarterly MDS, care conferences, and a new assessment on any significant change of condition.