Extended Care Program Admissions
Date of Birth:
Social Security Number:
Desired admission date: Possible Admission Date
This contact will be used, in case of an emergency during your program stay.
This section will be used to expedite the admissions process. This information is protected by HIPPA and will be stored in our electronic medical record system.
Relation to client:
Best Contact Number:
Marital Status: Marital StatusSingleMarriedDivorcedWidowed
What are the current events, leading you to an extended care program?:
Current or Previous Illness(es):
Injuries or Surgeries (within the last year):
Any seizures within the last year:
Current Medications and Amounts:
Program Name, Year and length of stay:
Substances used, frequency of use, approximate age of first use and the date of last use:
Are you seeking to:
If you are seeking for a verification of out of network benefits, please provide the information below:
Type of Plan:
By signing below, you understand that completion of this form, is not a guaranteed admissions into the program. By providing your insurance information above, you here by authorize Nova Recovery Center, d.b.a Eudaimonia Extended Care to verify and provide you the information regarding your available out of network benefits. You also understand this information will be stored in our electronic medical record system, for this inquiry and any future inquires you may have in our family of programs. The signing of this document, conveys your acceptance of the delivery of information through electronic signature.
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Extended Care Program Admissions
Agree & Sign