Admission Form – Canal View

Care & Services
Admissions
- How to Apply
- Waiting List Information
Uncompromised Quality
- Our Approach to Care
- Awards and Certifications
COVID Protocols
Visits
Life at Canal View
- Dining @ The Towers
Job Opportunities
CNA Class Information
Bill Pay
Contact

Menu

Care & Services
Admissions
- How to Apply
- Waiting List Information
Uncompromised Quality
- Our Approach to Care
- Awards and Certifications
COVID Protocols
Visits
Life at Canal View
- Dining @ The Towers
Job Opportunities
CNA Class Information
Bill Pay
Contact

CNA Class Information
Job Opportunities
Bill Pay

CNA Class Information
Job Opportunities
Bill Pay

Care & Services

Woodland Haven/Memory Care

Rehab/Post-hospital Services

Waiting List Information

Uncompromised Quality

Awards and Certifications

Our Approach to Care

Visits / COVID Protocols

Life at Canal View

Life Enrichment

Dining @ The Towers

Application for Admission

Please fill out the following form to be considered for admission

First Name

Middle Name

Last Name

Age

Sex

Date of Birth

Present Location of Applicant

Telephone

Present Home Address and County

Current Marital Status

Are you a Veteran?

Yes No

Physician's Name

Reason for Admission

Medicare Number

Medicaid Recipient Number

Social Security Number

Do you have any health insurance? (Do not include life insurance):

Yes No

Blue Cross Blue Shield

Group Number

Contract Number

Service Code

Other

Name of Company

Address

Policy or Contract Number

Telephone

Important information concerning the Resident Rights. Does the applicant have any either of the following?:

a. Legal Guardian

Yes No

If yes, whom?

Name

Address

Telephone

Date of Appointment

b. Durable Power of Attorney for Finances

Yes No

If yes, whom?

Name

Address

Telephone

Date of Appointment

b. Durable Power of Attorney for Health

Yes No

If yes, whom?

Name

Address

Telephone

Date of Appointment

Please indicate if you are interested in our memory care unit (Woodland Haven) for Alzheimer's disease and other related dementias

Yes No

Person to notify in case of emergency:

Name

Address

Telephone

Canal View – Houghton County | 1100 W. Quincy Street, Hancock, MI 49930 | 906.482.5050

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