Resident Checklist

Form 9 of 12

RESIDENT CHECKLIST

A. EXPLAINED VERBALLY:

Resident Rights and Responsibilities
Bed Hold Policy
Notice of Privacy Practices
Medicaid / Medicare
Smoke Free Campus
Services that there will be an extra charge for (telephone hookup fee and daily fee, guest meals, beauty/barber shop services)
Private Pay Residents will be responsible for all charges on the rate list

B. WRITTEN INFORMATION PROVIDED UPON ADMISSION:

All of the above items in Section A
Complaint/Grievance Procedure
Michigan Notice to Patients
Resident Trust Fund
Know Your Rights – Your Medicaid Care and
   Coverage In A Nursing Facility

Bed-Hold Policy
Resident Handbook-Rights
Abuse Definitions
Organ Donation Information

C. SERVICES AND INFORMATION COVERED IN THE RESIDENT HANDBOOK:

Barber / Beautician
Birthday Party’s
Care Planning
Electric Razor
Facility Personnel
Family Council
Resident Council
Laundry
Meal & Snack Times
Medication & Storage
Mail
Newspapers

Rate List
Religious services
Smoking
Storage
Telephone Locations
Television
Therapies - Physical, Occupational, and Speech
Transportation
Valuables and Personal Possessions
Visitation
Radios

The above was presented and he/she understands the policies and procedures. All questions were answered or referred to the person(s) responsible. Copies can be obtained at your request.

By submitting this Authorization, please be aware that an electronic signature is as legally binding as a handwritten signature.