ࡱ>  bjbj99 SS 8ll\+l8a+c+c+c+c+c+c+$-0+?I|??++?Lla+?a+r(T,)(M++0+(>1>1)>1)???????++ ???+????>1????????? :  Strong Memorial Hospital Social Work Division COMMUNITY REFERRAL FORM Identifying InformationPatient Name Religion _____________________________________ Date of birth__________________________________ Sex  FORMCHECKBOX  M  FORMCHECKBOX  F DNR  FORMCHECKBOX  Yes  FORMCHECKBOX  No Social Security #_______________________________ Health Care Proxy  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Copy Attached Home Address_____________________________________________ Name_______________________________________ _________________________________________________________ Power of Attorney  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Copy Attached Telephone Name:______________________________________ Military Service  FORMCHECKBOX  Yes  FORMCHECKBOX  No Service Connected  FORMCHECKBOX  Yes  FORMCHECKBOX  No Service Connection Percentage Contacts:Name Relationship Cell ______________________________________ Address Home _____________________________________ Work Name Relationship Cell _______________________________________ Address Home _____________________________________ Work Insurance Information (include Policy Numbers and Telephone Numbers for No-fault & Commercial Insurances)  FORMCHECKBOX Medicare A__ B__  FORMCHECKBOX Medicaid  FORMCHECKBOX Medicaid HMO  FORMCHECKBOX MMLTC  FORMCHECKBOX MVA/No Fault  FORMCHECKBOX Commercial  FORMCHECKBOX Workers Comp  FORMCHECKBOX Other   Financial Information (required to process application)Patient who is:  FORMCHECKBOX  Single  FORMCHECKBOX  Married  FORMCHECKBOX  Separated  FORMCHECKBOX  Divorced  FORMCHECKBOX Widowed Patient Spouse a) Total Monthly Income (salary, Pension, SSI, etc) specify amount $ _______________ specify amount $_______________ b) Total Banking (Savings/Checking) specify amount $ specify amount $ ______________ c) Stocks/Bonds specify amount $ specify amount $ ______________ d) CDs specify amount $ specify amount $ ______________ e) IRA, 401, 403B specify amount $ specify amount $ ______________ Financial Case Manager: ______________________________________ Phone: ______________________________________________________ FCM referral date:________________ MA applic. date_________________ House:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Spouse or Disabled Adult Child or Child under 21 years old in Home:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Other Real Estate/Rental Property  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, address____________________________________________________ Attorney Name:_____________________________________________________Phone:___________________________________ Financial Advisor Name:______________________________________________Phone:___________________________________ Has there been any transfer of funds/property within the last 60 months?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, state amount and reason for transfer: ______________________________________________________________________ Trust Accounts  FORMCHECKBOX  Yes  FORMCHECKBOX  No Amount:_____________________________ Type of trust_________________________________      1) Insurance______________________________________ Policy #__________________________________________ Phone____________________________________________ SNF Benefit_______________________________________ 2) Insurance_______________________________________ Policy #__________________________________________ Phone____________________________________________ SNF Benefit_______________________________________ 3) Insurance_______________________________________ Policy #___________________________________________ Phone____________________________________________ SNF Benefit_______________________________________ Medicaid Spend down $______________________ Long Term Care Insurance (Policy Info attached/ to follow) 45678PQijw~       $ ( ) 7 8 9 ? tgZjih]-CJUjh]-CJUjh]-CJUjh]-CJU hOgCJ h]-CJ h>*CJ hCJ hCJhoxhoxOJQJ^JhOJQJ^Jh@: h@:5hoxh@:CJOJQJ^J hoxCJhoxCJOJQJ^J h5jh@:5UmHnHu#678PQij keee$Ifwkd$$IfTl*+,  04 lap yt'YT$If$a$gdox  !!^!gdox ? @ N O P  = > L M N T U c d e i j x y z    ƶƦƖƆvjh]-h]-CJUj]h]-h]-CJUjh]-h]-CJUjh]-h]-CJUj1h]-h]-CJUh]-h]-CJjh]-h]-CJU hOgCJjh]-CJU h]-CJjh]-CJU) 0 z $%/vgkd$$IfTlc+,04 layt'YT $Ifgd $Ifgd-m $IfgdOg$If ! / 0 9 @ w z ( zmzz`zZ h-mCJjh CJUjQh CJUjh CJU h CJ h:CJ hy CJjhCJUjhCJUjhCJU hCJ hbCJ h>*CJ hOgCJ h]-CJh]-h]-CJjh]-h]-CJUj%h]-h]-CJU"( * U c d #$%./05<HJ~6<PV]ik;@GHISǺǺǺdzǺǺǺǺǺԢyjh}h}5CJU h5CJ h CJ h CJ h 5CJ h}5CJh{?h>*CJ h6CJ h>*CJ hCJ hCJ h5CJhh]-hCJ h-m6CJ h-mCJ h-m>*CJhh-m>*CJ,/0QH$Ifwkd$$IfTl*+,  04 lap yt'YTHI $Ifgdfgkd<$$IfTl +,04 layt'YTFvjaaaaaa $Ifgd'Y dh$Ifgd"G $Ifgd} $Ifgdwkd$$IfTl-+,  04 lap yt'YT  !&'(678DEFTUVabp~l"jg h}h}5CJU"j h}h}5CJU"j h}h}5CJU"j/ h}h}5CJU"jh}h}5CJU h"G5CJ h}5CJjh}h}5CJU"j_h}h}5CJUh}h}5CJ$pqr>EFIKǵѥѐvp`YSMCh=h"G5CJ hYLCJ h0CJ h=5CJjhCJUmHnHu h"GCJh0h"GCJh"GCJaJh=h=CJ h8-5CJjhZUmHnHujhZCJUmHnHu"j7 h}h}5CJUh}h}5CJ h"G5CJ h}5CJjh}h}5CJU"j h}h}5CJU| $Ifgdfgkd $$IfTl+,04 layt'YT $Ifgd= $Ifgd'Y  $%345ABPQR]^lmnvw!/0敏vjhho5>*CJhho56CJhho56>*CJ h"GCJ hb8CJjRhoCJUj hoCJUj hoCJUj& hoCJUj hoCJUjhoCJU hoCJhb8ho5CJ h CJh (vwbfWJ $Ifgd $Ifgdo  vH {' (($Ifgdb8 $Ifgdwkd! $$IfTl-+,  04 lap yt'YT0LNRu#$%56PSTejn<=@bᾲᥜےᥜۈہxۈr hoxCJh=hCJ h>*CJhh>*CJhoho>*CJh=hoCJ ho>*CJ h CJhYLh 6CJaJhYLhYL6CJaJhb8hen CJhen CJaJ hCJ hoCJ hYLCJ hb8CJhYLhb86CJaJ,;LQUtuvw#$6:;EFGHIOQR`abghv¹zpzcpzpzjhb8CJUjhb8CJU hb8CJhb8hb85CJhwMhoCJaJ hoCJh hoCJ h CJ hCJhYLhCJhYLhYLCJ h5CJhYLhYL5CJ hYL5CJhh>*CJh=hCJ h>*CJ hCJ hoxCJ"vw;FGHf] $Ifgdfgkd$$IfTlo+,04 layt'YT U$Ifgd  $IfgdYL $IfgdHInun\ U$Ifgdb8  ()$Ifgdb8 $Ifgdb8 $Ifgdb8gkd8$$IfTl*+,04 layt'YT vwx"#$)*89:ain⒉|ojvhb8CJUjhb8CJUh<(phb8CJh<(phb8>*CJjhb8CJUjJhb8CJUhb8CJaJjhb8CJUjhb8CJUhb8hb85CJ hb8CJjhb8CJUjhb8CJU+stu "#&'(2LSTWX|vpjdvjd hZCJ hCJ hYLCJh'Yh"GCJhh"G5CJhhb85CJh:OFjh:OFUhwMh7CJaJ hoCJhoxhb8CJaJhb8CJaJj>hb8CJUjhb8CJUjhb8CJUhb8hb85CJhGhb8CJ hb8CJ'!"$%&YdhgdYLgd7gkd$$IfTl+,04 laytb8T $Ifgdf"$RUW!$'TWYƽ̫뜓hq{hq{CJaJhq{6CJaJ hq{CJhh'CJh{?hh5CJheMh'Yhb8CJ hYLCJhYLhYLCJhhYL5CJ h"GCJ hZCJ hCJ hb8CJh'Yh"GCJ4%X(Zgd7^gdq{ & Fgd & Fdhgddhgddhgdb8dhgdYLÿhwMh7CJaJh:OFh'hq{h'6CJaJhq{hq{CJaJhA~CJaJhq{CJaJhq{h'CJaJhq{h"GCJaJ 8P:p/ =!h"h#h$h% DpFÒ_( : {SU(`JFIFddDuckyAAdobed      p  !1AQ"aq2Bb#s7R35rCS$tuҳą6FVWƒ&8c%v !1AQaq"2B3Rr#bS4Ccs$56t ?tP @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @(P @c˝ #37ǧJEGIk9>'j!'E4""o%ת/,K\iitzj,w.}>j|FL?5VoNGfu~[ ;MOY\x˞<-쵤5.>-k^wX@_ɸ52`/U_Ɂ0ioL^h >2ZIfA|io|",}Aֹ%Mټp1W"_+.Nb_/a߾L&ŒKѥ7nJRF,?tP썒&Ӊ3_[-Bd%Xc/OTiǕc~Gې8щT-5ܚzjP @(P @CG|gidI<_ F$ 6'^ԫ+X w5ϠvP|IK?- K8jI 'UqsyTeHM)J5|o3 =6Z& 7F:s_UDP`[^>3# YS{ϝӱx k~qw%48* /קZj&ɣ҄gU]>4]ܓncSDQH$Nە;oJ5bR·sس=2Xu݅'6ĆuD^B$/:ZbfnrPUQ44yԌncrhWTBdS]-{lVtoV\l{N#yw yީMJ9⎟8ҧ6B^׸ت*K')XݽS M]nGH+6\AjHI2qgFeCl^ӻHu2]r%keM(\y6'%ۥeDܔ1v^yjn{N1K,CCZ|  $6k^Mj[lƾz[{pKO_M$J'cd1QQDRjI8j7W]\k[}&ҿ{z owyi$rJI.j^2gOⴭz N"\Rs[A.to}ѝ'riNvfU܍"Sd'IZ'zغV%m2RH (J.-6e5P031ee U ´Y9n]TwV6Ǻ4)st)B"T^ݩwpai)ѾfD;©s{ed—٢!Ɉ_Il' eYRGqcv[q#$L"<.ke} Yٳ>!ȃO"?i +}t4ΕYA'v(3Cy~;.6]P=+Eka2=YjF[;[$XģPIxPzZ,+Ww+bk~yΏ+Gju9ɌnQ@" :/7-=RI6rȷQ̌q6Q^GT;U֜oRE{asU3ʒtDA`SA$UT5YX՗'c~Wt,9(6})%ɖ7ݳjsԢ=`º+Ê8[7[qٺ׽"մ{ ݵrnCu\T+M9xTM<΅=Ȩ:] Ůտ V&.6SPoE<v.8܋޷[4+~CMwշeS8ܓ{1 g{+-U-m f׬?b[UBJ7cyanNJ{з])7 sv2~|-jj+hnziϛъjOjQ|SQ$tU[UE%oʕ)JғT|F͜[$dh20A7x׭euiX$E+GSȏ)?2v߳t} ʍ:*)4-aO!_ǂW':r\^?/2b]ؕ\dt#OMȑqOUA^F%%fێԷZ#d00/˦]i(x;usCF˼n =8+c#3VRPNRUj'nZvmkG"@" xNu?h ^aj祌,sd rL–%EgnԮ:EU\jtG*y_"ޞy=F>Yf>l#6+"wp¼m#\~JebM1¥gAwSYE~%As̕|E%\/G\YvHPQS(h}ۆ@d&3SqMR䊲m+-bI{QdT?W/}PI5>kھ!2# J0GO{? /ʟ9IC͇7'G܍V[n.1SW:G*U+3_gc-1zmGaF{O-[w_k58u{xzm<~`?t{'>=~y~D`vYAD_["[uU y>|6|m:Yj]n]2 6x}huۚoi\B, uY,D$G`n^+՗ũ"kzֽk stQf?/QYx~#мj5ٌ6˼ěK̽)u{Vm3;IV%=<(9(h:Wz]Ƃ\Šɛ|f_rYlcHg-ɹo d;:}eb)WĴs6/F;Mf?dF]$V^wO5[.EaKiaXK+M:UƹvURvM&DP VKauUQ[**tUY3VqՖ?fqd;D}(XuUAtS*:2ݪ~x%k$+)IQ>"10BTTTEEEfS/J2k*)gt̜۵5-m"pu#%N|R[k-Z˛7-^q"vkw?QMK:'YD/j 'V|_.|O&DYr#4DG #hP%K*ʪT[KWywiogqAp~QZ$6 vQK SZ_yIxWqXo`/#ל5*SkL"''OU \eq8䇗} OR3QAѶ6*ǭW]d=e*n+YP @(P @(P @V6 | @7`NҐ[xD/}?:,}NߦBE-DRz"'7V?8u_oԑ[~?n0g##$禧,i {EqP|įn>u܃]7Q㣟>RصwbLepe}S1D v7)?Y;η t5Thwk2uϿt?$'q뒲0*ƒe4'MiUOB_{eܦ!>X[]ko{D)v/݁jo33Fb($FLmUZS$4_Wiy%(WD|Q8JJk+aBwkZ-9:kvO={z}_g?1!ϻĐ`nT䈾?ͯq7_Kf+Yd(!Q$BK*/TT_%*l Ÿ"YDL6/!6 N^**_uT)8)%GSS򱉁;;NŠW[PW%R+_r+gQ[L8LZvD6%ATXj2q^J)D=Odb3X (px8'|96o4/ W .}e~O 5Xe i8Xo|qWb%T}^P#DwIYs[Ե 6&[h^]>_j/T^-&ZX @W?4X |ژhHR) '\pңf޹'d1 91dHm&zr:U}[dYVcQ U]c&}/"CmleA~hk–R.,͜q0*o 6*DVDJۢ'6"_7-6e.22$jĐmk*vD@Һjۻ}0LkC\# DvQ_Vy1*潞&岹Vܳ=2''<($wAGy_UzÄf62}NzFޡb^YEUN*yD|2nE^\M%eӓH)R["Vmm-eZɄo{98ɹ\t]mY`dvīRZ^“ 36޺ӴGЃ#|&Gk^ I=TѰ.=~Zv"ڬLF1rLCp1I$lThUzb-/f&IhJۯ۬7}[Ye{} +1bt4NWx[(ͶwJjIwƿf@2VaYhFc D"<;$mF9-&O{ȏzIv^اcO1qҐEa^L i8q{(A S-뒍ؽhnj]o_/S+>Ln봶- !'ފn6?۪`Us_/J|33{ӵ巵FT<0miQJkk'az]Ϝ 8̲>W;l泦ٵ<>ߠN';Ck?zqQ#pr-MQ?4 mX܋~SG>ஃܲs9J0*B܀XW*ӶC+qRJƿk9N,sFqbdhJJ⒕-|+ۗqNݘ[T9ǻ7G,:A͒/+L8 m[Vu䩽5<+-tLF1H cxa|IPS/Z;YH#;k;q1rnCCH$rܑzuVVN߅Ҧ7,~%Zo:2+wی؛nD袩tZYWZqm'US]!:NJ~><ȸFkKWվ9WR4KuqUfnKԵG7jˏd5mI AHRTVEcrɪIe FE}Ȯ83@s["/NSƶۿ;~JY }q؝ YGv;lMy tQT-e,Q8փx9=٭_Ƿ-(SȡzO1!Zaګ+hyt1t*N!󲚛ln6EC-0@"VN++ҌtB:lXpnR)k;jIP @(P @(P ؝sɨGW@c%odSg0rA C~"1OaŵWSYC.;֗N'L.[P{"Λ)ZFSiE/M'bGJ,Ъwl"ۗvbw_nt N˻]T2YMd3#:ciu@GP'%av1U7 3JQNh^?\g G$Ge_eZoe3s'CG:ж-ޏrs-\Q{}7m;ĝҙ·uXy,dΊ*t JYϡBd*T%NԤO1vQ AUn_{j;rmd75('\k?r9H|ku\D.к"D}/Zo7wYBNUw=Ɂ\\ϱˌfIy\^ ) :YmjcUݣDI)*>Wk$1R2nx~FZ᯺`iM~G Ũ\R5Lᒥ]I#MYf] #"y_U^fs5}۪/8r͚u-7C7K1?EV"PDmPk'$.Q~Z8 M5G5˨5D^ ώGU"ʊ7$_¬^xI|^J]'Q򱇑Sf^sSO?X֎/4(/i9rUIjGv.6i #=IG9.K)/KÝ:ș\ǯ{vObh.ub/îNx3|=_j"r }? 5~C{Y'.2#7Uw tKM>)ղѬ?5ܶĎǦ9-)ʷBڸ34ʴʱK:&.c˲&5;!.Ԇ԰հ(y"*˭T.u°3۵w^\"?m$""թֱ'(IGDz2݊ߗ"=!ڴ5'ŝ6*$U9=O4<T"k*>AǛt>5Ë~4mt/+|1qDIQG. |yrjnt*δU'BOpuq(`A_?%UWm]It'q;ޤN4?&K@DDxߥ*V656NM:\SCw~k毋pz["#6ulKzOO1uh;o0Ũ^7ڗa'19]}1xqBAJ䨂8"ǸTM-*]Xgɴe̜&$ȭ ЌQWQ*ɸ2)rozF}F+jcbuUER'U%6ev[̀dU/Qߓ D0-]U>pʏ$u$6kR1#w"r63[9DK"]Iw`>B^̼Qޖ9JRkZ(ק9۽Jj$ሂ"qH 6,@ Зk{U7܌\ѻ!vdޛZ]īɌx#zlYFcr%h>.*!^B*b%eNHZx+zTQZvo®[|-mPIl|?S:=R}Mprd)҄E&mErlU E|Vjv#XɯrFhdc]n2m;E#yw*"ړ+E`D[J]|ֶ*_v nޜos[;F3E8,sv!)?TׁX(/WE mT(Z'sdc0ުD+Z%s[I=|GLRH;'5|q nDe*:UVxЊc"VPÂIoL]w>a1?յ"ı̟GZ;Ծ:ީճȜ#շbl;ҷ<"_Ğ*ku*Eo_L83r'lɲxrC4xf׈G4D'WRķK(b]>p0lvIJFl)⪾dKu%ZMNO[/B*+R#Tk1]*Q EO**eJ~_/4/X%3frz#\qx)]}GR⨝.Wrk/.:#OQcR>d^xP]WnY8,q H"=F덒0_ӥlvVfr;Swaq%fpjt 1r莈 ܷ *K9w'u}ܥԇ2.B$yh-pPT[7(dW/.:惫&f2pĺFmS O'G1Ï_H=\bDNIw' Ɛ # -]}Nµ}$,Uj~'% Mí5!}uEA֍$QS+xHϵ:\~\kT$au%@UFf_WTM$lQ>כ ]D>1=ge+Oԉ/dP f{(K IB_Zm橓,u_?ؿǩ;ǯ\GKڈ;Ck?z8ƨ8Fu#&Vd3Y6$^ۂHZ-e8ִc(*=LjZ7\nQLoҴܓ!D՝dܵTͯ. :U 䉛 ?FӯkO8Mml"AB)}$@ʵӬ)Q^~?KLNgp㤋--iF&4ۭ_R%z1OcvRk.nĀ܁C5St[Jr.Lyvy5~`|9%WxokgIHʬLSJ+ۀqs99hOL%4d;[Vhbϗ*W͢%շU| V|c7˯yN?_<=>獍SD)A#z;WD} UimT4߲=KZMl_#QþDzϗW`UTZUTZ:t6ݫc7-~vlN<qQy}7C@]Sx-lzVwFYM;!}E>3"PUEr|QM۾.^P @(P \ D:Qqbo>唸ة^6$U徱°2ں$ <$Ț57m(o3f۶*vW#J֦}-3j.XLf;[&S5&-n6VFE!NwZ_6 qkΕI:Ov;eЛcVc'rSRҦj=7F-!?1Bv|&HpVOX=4$j x{nݵoiޏq7^zjI6/)UScӰpnӍ@8'LlDX* 饈|Gĸ n˳spJ)'U{Ob^|;&ܥ1TtUӥr|aErrK&%4SMY#%>#s"%sτ&$֋oeyj7mJ͘JQҾmF ibρ Ge<<{snN1iSMw[wd6[QM׷tul24 7a6MsOh}zz]4%*tVbxV{T8nS:#;c^8m8n-wR$䶮31p|6S:EGzRihKM^]oYXjpEEkS3/w_s+@a8Qdɷ#;]=G?%cX˷rUV;B*.ܪs6߲['nԢQPKm:"y1yؽO:|cLr-zܹ6 eܵ;yVbRs)Gr:S&ՈڅRZ)"oJzSQ+mWq~HPOY-k.e˶nG%(N-t5'cgZqIz=n{D=n I^+Nę%44lQTs"Aε=2xtNl؜U'jܻFn$޾`[ȍ/)-~5C;=jY̜ ʴOI"q|/JW"Z~sc ^Sj \RZ)ISg!?[Ƿ;ДN: h{ͥqa-lno >|]=9nںf[Hs㌡HB訽}k#y@C2 IjDžWqOֈ3\l9xfRD',\Ե|*ψ݌"-;JjStl$v,~fcDrT#'+gx[^x6%*J >nN=Ʊ~h~m̎g/$Y^㈡9˒/lMqTغ)\.90l4qT1*ݸ(*{mrNuzWNZF+ܗVe>)+s]^, +7v~bEf HZY`6("Y6Y$jP |X"<.;庐̢wQ)xQ&,WhV(4/y{q6W Du̢O#8˪0,}AoVrV:rSUv-}TE_6?~5s˨v?-ҿI*?HO[&J,E(x5[+㗹k\G?SxwϏ_ȗW7wXqQ pr-MQ7mdyқY&̏ 1.&\@#^UŗrT[M7+jkVqX>h4y;{;FY/頚.5_/wW|'!*}(~.MGwpEninB '@iN _B^p&cRhɏ1Dy^6_h0.BBJiF]=k@( 5~`|9%WxokgIHʬLX>mggD{^1uU'P}^_ KUsr6,ptW2>A%1_UT[ .6ҧIZMl_#QþDzϗWs4{fъӰ36 X x43^+mR%jv6ʱevmw+x|s>/*(]BDښ*x*"y[ַ)8uN/ip:@(P @(1P4BEBKcqv!j C%.w?JķUDJgZς]i$)_*>wO77뎯-] n&Z;yu:ӗOMSa;%R_m:ڽ=?26e5s$X-Z#PO輋bn쩓w_:|]_w^w-N* i>׬ky^'zpiՎ2T쪞3w'';rtzm:^RVv[Uݒ{ [!nk-5No aH*ԄGA?yVodO؞B-mU%UJPrznNrh}s|t.{Q#d`uf2z[p-oU7"uJV/ZM1RV^m&q$!:Q-5ÒkG$qlCpx"v ;qފURS݊ޥ}ΌQU_QBv,9 g2,|tT~dLk],lJ%[֚馒5E&[j[5ME9辳PձyҰ÷˪:?ܗ[$(P;*)漶*DžW簿ֈ;C?zqQ"r-Ѳ%ﳾߘ8#=:f^u9#尿%ǖ&.-⌗򘱫~˸ySұ;޵?;!<"{ۗ_gFK{N{r'Z( ߚ/G:}c>?oБV|'?W/ogtMuUEt[t#ENS_ s_/O6uqW[2X*'V${M<5:P |Gꟷ .jYl&[0%?!SIZmmKP\n+<ܨBN \8Xӝy!?_9'mN>D:Cs󶿧N;ԗYgl;$_ĴYNR^e`k3 ݨ͇ԉ椦Et#Ku^kWnjV*QqFԽ3"=M>=~B?"]^@/_ݑkF /]__֗կc*Z!WlyFNE٩Jܝ&JW[%V~yN'G[ir:ۣGlf&LYd\Vj%:R)ۜwT^Drr[_IgjIK+}AiY8 +U'D_a/yҊ*}[w}hc*OS.a{k75E5OV;P?oI:*~*21f[:<|ގ:ot| haذ>=s<G[:XFUbd( k??%]R񏃯l;?"vor0MYDڷ)֮- /ȽXfn^krִ2߲kvgٌ/$T&C<ӥң~yNȿO;gL;˙>sT902/\u9*~?ko~VBTjf\wk!֋U%D>`?{'pk9~#E`{6Jh)cᠧdB)骋w1[YqrRU+ƣ3wsQlĒd+ ؊p1eJgr{iQfw>ƋvCaXc"` DQQ=\mI%DzׇP @(P k/[3Ɲq\&W\~7{nrOq/y3߹.EdiNѰH]eE硓Չo+*‹L=<;ʵvTeJc=sXV1Ziȿ<+R)SmVKTV/[& 4N޶3ƽ%{񔥺mƫLwvQE(c{߳B44t)Wmg}ܖ\dt[a]|Wta[¾)ޗL*_| &#Ll26!گrJiS ~Lǵv#o A#MmČN8nJ[n8]ȕHp;v]˔r"94Wiz#Gyv;;[_A)fQlFI2I⠾Cl>bo3ZnWoǽڗn;Һӭuλɱ88̮;˪6+z;Ck?zqQ"r-MQoq;]ʏ4".V P_z-myښje]Py,lUUBiĺuOMJ˳\qٳŽR۷9 P l-F+a([W|"ߊ}E'Y ;GLGkUTzT,hĖѦoBgo^Ix7lELer}d/y!W죠߇U|o(gDGd$Fu?)EW-rsiGW )$֦e&BP 2",z>=Dh@MGNJ"vo*i\~lOjQO5G]uXru%pߐP P;b!K3TVȈ]M{^XG?SxwϏ_ȗW_cdmqQyΧ=~ze-%Qg−X.e迎?WQn϶ͿYȵ,O2ȩ[\Qx_[p[?\ĈG-.&'*cں )~ZNvVv.esD( !?ؿG|Y.b/.;>fZGR2!@V_Y*}^|~OT^눋uOE-B?>]^M"=~J~q\,n_+l_#QþDzϗWs*wl0giԓ^"][!~_ʫkZ.'GGSw/M:i8"kr:"~Ӎ}Qx'-_v_xUbP @(P vLesߕ:oe@[ղbA7BTXh4%&t_o8~qj4OC`q (ǭHu$t[ SҊ+ƊK3 AK'3q2DbJrV8/dMHτ],{ W*>c%rRSә i򸯊/uEJmx_ R]~2q^(p!mtVɎ=ݗ\DUYnV4Kl }{H&2;.lO^{WQ θ[rW&?ۗ>F1[ (:Zuvʐ6Îٶm%m܁xȜ|-NOPqPsjQ۞ð~+Nb!}^j<΁ H6 @8Q,^z˝iEj$bB۸dy(R$-Y6گ E4O*n<~"菎? nqEJwSEyJ"B@J*H(]ijZ3p׏9缚d}/jHpIONоԞt@?5Cߡw^ܰ)[ZNݮ<6Ӫ+Dgy@;=d+#(i Cx1AFҁ){߭u2{Y³EF^+G9Rd6jhi(tU6C1U{[k7  p÷;'F_Nz+8%>TAѺ]qz'u+._9>1l*'֮M -ݰOzTDIԃZˇerݗ[q $Ƃ۠=LS[ O?V[Zy^e-1.RK*a\k9l֧KI<@ISιI*3r3U6U; F½FT=i6Я%IJbĮv&j;+vv{F(GAq$Bދ@$`K⪖1Ƿ[{><۞OQj f݀vmh6hU&4 GytT*;+3|^5x\sG1t j2%.+~nv߆i 7OWgBj~:KS!>(WHQٳ)*(ȯٷ;ټT˶°Fe+巡f̮v&ףj;#.2ڦOVϥe2.9((n⭹6/']e,J<~R" /O^'#]>mԎط͔Ӣܷ'=պyٱ*//>ى\2&*,?ܼٸ)Cѱ$꟱ղ"&)ےɥ3}x6Ǿ+ʷɤ<{}z+\$4k`6!iryS5u\D_LVq5Kxc~Q옝O /;1%UTgouU9AJjԮIF:wn\YZlT7*Dȑ|R4B> 2+d +.::XKSnwuvw11aT? qWXmF V2孿FmŔIꧢ&^Zt4V%RnkDUw6{%磕.Kz}%M$#C%TOӵj0 RGr[o^bf{`j Ű @lD_ː7[K*u|qC{*Nݷq=:,x㻷Wy^t\"H/|̇uQRI"In-ׅJޓ~ETX!eRݴ>BŒWx"TP -aG5:>:* HnJUJ"g8VN0׷6x fB·2jdꏦ4.(uW7v)hlYpHMC33^g8r]lTե#Bʃ#?޷HN| feO^um \(Nɢ]M8kbvJGn.x]Mj6wfJ}W^Uw)mzKěٽWX^ek '}`Dڂ<ѷ#~PĔ~ ^d5\rn>GDu e뼬xab{GO,O(ؽi29-(?do?@5IGe& 0ۛ$1xx$xҲ@l* ajo{y%--]+GK)ٙ$MVU?M mSWḦOۓgz+0-Hg hhh{kRJ/>u%O3m0Ĝ_HhXk^C sDDoz}*mB<񛶾榫[Gj_[݄OvyNN7Hy ?ZV2g .h(%FQ-4,bZ]?N;oaC*p > BpT5Onr}f3_.}~?HDT٘`ߧEz箝+ZZg7,#@m @rR V?هL#>o`l+y, ,E]K'TmW3y. kr}gchx>a W;b@@l)Q2%z[$cwbrwb,óp{#>9>? q60%uQ}GZY?Nk9?ed>\~[?%.HA⺭FKγJ=prwYmK"Lf1aXlض"!⟇΢!NM)7ʉSRn)r3_d%:Ku\tEgt4gof^a/ֆ_JTkRFHZ]oQ&_cb5;$x$(BENRX33T!>ZH kټ ϛ_)7ۊԖWTpNr.kwxf]R)|nM@=Z%O JmkYP @(P @bd38X+5fKH ,OSVPMkF3ʉe{!ɫtl/$(l6+з>VQQp(q>mJ=SsWLe˓Y], '>Uϱݽm=TFߊI*TȪ}m~L N[StLJ1QRf[q^7bЖr>ּkDPG؎]adQ~@OI/7L,3{Qu텷?s—H1X^u iI?.un]s!^t̍U|y)~S.pp\m4UԷԩ1v}EvYv0BF8Ċг;b qlDQ<,m$^@cNX(͊JLHl]mTz*t'Tc(*5S6 xB6[E+rO[gVWq[ ?x%/aa ⱱ +~o^\#n1Ԓ31@ad,oύe s/mz"g8VN$c{k7I4ER1OgZܥzڏi߳.۽_p[^MID_03CM٪9:TUMKi0;"*.S,!x-1^UlZ}Friu)./D\/S4}lrߥ^yrݣ=#UNSZ;>!_щ:}(uǸv3mKV\ac GԶ ʶR%^X3J/^tR]vC+Ĵ/gGvKW)"zV1TSug;2jfO,Q^B[5˱MG[5ɘ!) dUN$Q.^Y""TDDZl94g'pߓ>2[ݲtߗe?ڍ3/6.%r6󳾱ԗѤ%*3'*3G"˳ι󨔌%'٪ħSs8@ŲԱ2;շe`+صϱ)*T&2!ڶiB6"e:N638ҳϛX9-ܳ0#Jڬ.~t21px97[%%ձƱĚ2ذ6+>Q2&><^.GO#R! +|1nUE'jHoZnOwTUUFP"*=iZ=nz#$ů}rq_#lz-ˇCˏ$-N~AB&Itӿ+.}cKpy|0HyF+>"ˊ6enQ֚2SL{sK{#b3>:Ȉd= ЅSJXT]: ]iW.6H`h$+tT^ZN–>fNJ>:?ٱyDmV.5UNSm:9*Y!_r1\IM*]RrN׭(=մGcmQK~^=ծ/dZzOSL\@ȖtdDOT"}Ϸj=V$#ZǸz9sh GY -*^\8SyRBuumgPz*Ĉ_ ȶ(wm0mdĥ/6:u%'Uy\/FvB1(*r5DU3U[>h-n zF**/Ҋl߳.kͯl[:L7ÐԎ?_Ejvk#? ObP @(P @(P]Vn8wy* SDT/1E tUJjz/I܎[/{HhOa^V^Ѹ~5r [Jtk|Q䗊@ʻ-w׭sGͩ}G_ܘ-T)HiIl}O]//_u\r]9=>8tr0,:Ĕeʴ* s^#'h0@ؖK TCh\*8v' ϵa]aa=tnĨ+[bֿލjϨyϓx$芧6A#صY|>*Y%q052ӷsG*=s/%QiRӰ뺷nb{=0eeJ̵F S+uSqycaglkEOӏyOQqg>eY=^m}ɠ ]"EUqNFV:~_u{.,4?7*J)-$WY]viY[=5rxs à UU^DHU\--Vݎ`f(P @(1b`a1K8ˠ.'DQkuG&mȯlaOd+fO"'Ou<-]뚊~Prk\Yx|ׅ9_-6*d_RkgA)(HCwrl!e">ÑĢ ' aCǯ^~^- :}%eVkZ[BBeXQEoǍojR*ַ`K5!bYmL(͚H񕬝'78Jh+Z&8NQu2p$U.!q&y b?Caou*\=AImݕV<,ͫU8mLi f$-OS*{%P$7I/3..pTӠ+37I:=dOYM:H9"{U/Xq ej 6pvޟ".jH}ԛb4,EL,Ƴ=7@m!-u?U}~}*{K=1N8# 쓏hA\$ۢ{j*W&˩8ۋz+ja?ލ/@3ؒq8g.pq˕HZKOxVXջz8y7˚RԶ+'`81TT+-/FʕO zKy[sdhl.VLY )Ct[ˢ~TI<~]zJ[iыaً7{ƣv' #ҭGeQbӹ5Sm w^fiLVu^0Y o4ӫVr}KWTE^~ipԱe,s-Lg@%e[q{Sš-Jkd|&+ `[f/cb;$udHDE2R%[@ʹ)\^Nŷۍu( 6\Wlw4ע6.*Jwe$<9RV;;D9VDhz捊cк ɞ? Խ<N&O QQ]u^CpODd $"TT'EWETU蕺[V iMh5]Ng ='KaK5|F%Z'TUTq{Q" Vkc!?g\i9yyT˖qYq}E"]/uT˥YqKĢeo [m%vV᤾7Aˎ5{{JSU:*T>Kʹȳ?0%<{ !ٱl8,ڳ7ޖo#n徱01h$-ɻ+ѬGƵVȰ/N<-q|.jo܍)4h-\Su$'@7q& aRYd@Q Dn))ҡ_wTk;yI1է*jB g\&q؃sXms(KtivOnU}f]*ht۾g6$ ٓGΉ X|Lա een:Aɻ\'dcZv2zrP$KG#eɧTMSTe_ ǎjgh * 8Uwr_OaIn?_i6?R.o9sqSycay\ǢY.7qfceA[ȏOb-eQP @(P @(P d(yAP qBEEJ2quZ%%G;wS 9͗0nEq(˧q!U;ʦ^6m'2 *%dY-rz{^lb$"82_CQ .q.zDdYurBRغ-%[kȆUc1gnmKzlp.iuXCj(B.H"T?B!sL2nrz5ڄO..4kMh]ԺeVI:Wڻ4v^N\`O26Q.ew"5g ݵȩӬoS}Ӑa̷;`vY<* meTzWP @(P p=\<3%ѐKx쫗{ILV|fֺvOvp3ܶix/O{uUEbrfFuX>jha (ۨZO#4DN\K~e3̯ [Y$NüioGh#2hWt-\ڸi~ ەu_1;i{4J;{@K!g})UwNSKAgbL#: GW؉9]kWk! :}$ɋ :5_^XYn̴^f+]lf[wVɧS$i~Cr4SxeUG&MFQ.esDpp@UǸ*A* EX_:=$\ߓ.lG^I[Fz2UqbU擟.$̛$! D'TWx2qƛZΊLEd7\1{fKcdcL}F(+F꒍xpVt0.)ǯi!P2~2Ks!8!C&\&0!Qqtz.2RUZQUF;܈Nr'(⸼(M1HUMoۢz(+ZשhYݼӲDc)&.[%$D_R)Cf1_}{u?NR |(P @(P @(gu `l(T[|zr@_H-lvPuRJ# B vM#-d|zy;Y- TF°3P @(P .no_JO}[1#Jת訩uCMseSmݹ`e__U7x`y\}D[uOe~VTo:\8ҲXS2cY;<,I{b6QB~6Њzj#ty^|>+ӓ8U>ԛz[B;$ QI\xz_I/廓~gY.HEkf/jLsBFWz\}߶zʠ)C~WOq+姸avjq;AϺ[T5w6}>*8yU7;{ GO}O~q{lPg{7LVtF1MD'I n-Zeڶwjlv⤧ Xl[S8޶M'q#BR96Ɋ4TDv#jsQ, 1Z6 #F 6(| y]zե! q݌4tEe;ޔ}dɯ@ m,k $Q:Y qzU%jX[^H笳"&޷2 !2⪵2|-/Frߋݑ.BǽE)S,Ը) I>f5k.LSz=4mgCi0e ;%%M_!&Qת޵WnoIwywj_{֯]Z%ŽFnP? "BI?Z]̷;jKVk.9սz>f78a ,2mpWPQ^>"6XTU~ջ6ĜԾNܽձ<^ӻIr5΍ǒY.xC-8kXAky!8B%lz6uCO.c;磒YA7ShFB4u<,tpYlxz骨"]RMbRGcEsNPhG4y2ɘ/jF]z7֔Z7XJl9 ;b #8+]DTG/$E_|Rٿ+Rމݎ_qp,Xc6U[ 4JC{u6]g*d+x脻ӕڱ[N5f e!QG LȈKS/g$`D@U9%PU+MFٱQܷpo,7 hE,$Sޭ- puEd}}ϼ]]s>**#<7VdXFߒ'KQ6?S2Ad:h8($fJIu$O5W;sUOeMѳ(ZP[hGڗcvm?b{gbY1Ba ]qpJr4!J pеw% ۞򞗯sS\S5 2^ہqUk/fJѥ=HZt>S'B\fӰŽ7 "*B*CJOJQJ\]aJphPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  P ?  ( p0v"#%' /HH !$&(8?O=MTdiy    ' 7 E U a q  $ 4 A Q ] m Qagw#)9G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$l,R$_( : {SU(`˒:P@D(    S rAT  http://urmc.monigle2.net/images/foi/b.jpg#" `?h  C #" `?   L?"Text Box 2S"`?   L?"Text Box 2"6?? B S  ? QPht@ t85+ t3+t Check10Check11Check12Check13Check29Check30Check14Check23Check24Check25Check26Check31Check32(?=TUQg 9PNecbx!"$&$$09yz&$$09yz!"$&,cX[ "8 e%Nng`VH^`o() ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.^`OJQJo(hH^`OJQJ^Jo(hHob^b`OJQJo(hH2 ^2 `OJQJo(hH ^ `OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hHr^r`OJQJ^Jo(hHoB^B`OJQJo(hHh*^*`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh ^ `OJQJo(hHhj^j`OJQJ^Jo(hHoh:^:`OJQJo(hHh ^ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hH[ , e%ng`         f        f        f        gfox3z`den y @:Og*E0iL+Q^+d+8-]-d-Ox..T7A<t<={?5A@B:OFuG.KYLU_%XsX[va)gR^j<(pNrq{:~A~7-eM:o2-m"G & y>H y=aNHo3b8Z'=wM\:'YJ{z<o7 ^P"~ fm4Mpw<bIpG?S}IR5>@@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaE Californian FB?= *Cx Courier New;WingdingsA$BCambria Math"hKd'Kd'7G $ $!243QHX?=2!xx˂ *Demographics/Financial form for SNF packetLauren K. Jabbour Smalley, Marc    Oh+'0  0 < H T`hpx,Demographics/Financial form for SNF packetLauren K. Jabbour Normal.dotmSmalley, Marc2Microsoft Office Word@@~ G@*F@*F՜.+,D՜.+,\ hp  URMC$  +Demographics/Financial form for SNF packet Title p-Ai      _PID_HLINKS ContentType Category17display_urn:schemas-microsoft-com:office:office#Editor TemplateUrlOrder xd_ProgID 7display_urn:schemas-microsoft-com:office:office#Author URL IconOverlay CategoryA*http://urmc.monigle2.net/images/foi/b.jpg Document Nursing Home - SNF Packet FormsJohnson, Kimberly S340500.000000000Johnson, Kimberly S  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqstuvwxyz{|~Root Entry Fg Data r$1Table}Z1WordDocumentSummaryInformation(DocumentSummaryInformation8MsoDataStore 9LA1QP204OA==29 Item  PropertiesSAL3APWF2FY==2 9Item  Properties OX2ED0TXND==29Item 5Properties  !"#$& DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. metaAttributes"/>  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89qCompObj%r