Admitting a Loved One to Fountainview

Admitting a loved one to the Fountainview Center

Admitting a loved one to Fountainvview or any skilled facility is a serious decision that can be made easier is by the effective flow of information between involved parties. It’s important that you have information about Fountainview and the services we provide. It’s equally important we have details about your loved one to determine if his or her needs can be properly served by our facility.

To facilitate this exchange, please complete the following forms:

• Inquiry Record. This form starts the admissions process. It requests preliminary information about your loved one.
• Medical History. We require a history of your loved one’s medical health.
• Level of Function. We need to understand your loved one’s ability to perform routine functions, such as eating and bathing.
• Information Authorization. This form gives us permission to obtain medical information from current and past providers, such as physicians, medical facilities and other skilled nursing facilities.

 Download forms (Adobe Reader® is required)

• Inquiry Record
• Medical History
• Level of Function
• Information Authorization
• DMA 6*
• PASRR Level 1 Form DMA 613*

*Ask your physician to complete these forms. They must be dated within 30 days of admission (not application).

Please note: You must complete and submit these forms prior to initiating the admission process. Email them to Heather@fountainview.net.

If you have any questions, please contact Heather@fountainview.net.

Want to be sure Fountainview is the right place for
your loved one?