Assisted living home for seniors with dementia and Alzheimer's disease.

Rochester Presbyterian Home offers assisted living homes for seniors, dementia and Alzheimers care, and senior citizen respite care. Located in Rochester New York.

• About RPH
  • Our People
  • Our Philosophy -
    The Eden Alternative
• Assisted Living Residences
• Dementia Care Community
• Respite Care
• Financial Arrangements
• Resident Application
• Calendar of Events
• RPH Family Scrapbook
• Contact Us
• Home

Alzhimers disease care and adult assisted living provided by Rochester Presbyterian Home in Rochester NY. Also temporary and short term respite care for seniors.

Resident Application

Applicant Demographics:

Name of Applicant:
Street Address:
City:   State:   ZIP:
Telephone:

Current Location of Applicant:

Own Home/Apartment With Family Member Hospital Other Care Provider

Birth Date:
Sex: Female   Male
Marital Status: Single   Married   Widowed   Divorced  
Religion:
Life Time Occupation:
Physician:   Phone:

Applicant Insurance Information:

Medicare #:
Other Health Insurance:
    Policy #:
Long Term Care Insurance:
    Policy #:
Prescription Coverage:

Applicant Representative for Financial Decisions

Name:
Relationship:
Street Address:
City:   State:   ZIP:
Telephone:
Home:   Work:   Cell:

Bank Power of Attorney: Yes   No
Durable Power of Attorney: Yes   No
Conservatorship/Guardian : Yes   No
Does the Applicant have a trust? Yes   No
Has there been a transfer of funds/assets/real estate in the past 36 months?
Yes   No

Applicant Representative for Health Care Decisions

Check here if same as above.

Name:
Relationship:
Street Address:
City:   State:   ZIP:
Telephone:
Home:   Work:   Cell:

Health Care Proxy: Yes   No
Living Will/Advance Directives in place: Yes   No
Memorial Arrangements in place: Yes   No
Arrangements planned with:
Anatomical gift program: Yes   No

Applicant's Financial Information

Monthly Income

Salary:	$
Social Security:	$
Pension:	$
Other Income:	$
Total Monthly Income:	$
Assets
Owns real estate:	$
Life Insurance (cash value):	$
Savings:	$
Investments:	$
Other Assets Estimated Value:	$
Total Value of Assets:	$
Liablilities
Home Mortgage:	$
Loan/Installment Payments:	$
Other Liabilities:	$

Additional Financial Information:

The Rochester Presbyterian Home is a not for profit Adult Home. We respect the rights of all people and applications are considered without regard to race, creed, color, age, gender, marital status, disability, sexual orientation, national origin or sponsor.

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