Loretto Motherhouse 515 Nerinx Road Nerinx, KY  40049 270-865-5811 Fax:  270-865-2118

Application for Admission to the Loretto Motherhouse Infirmary Please return to the Administrator or Director of Nurses

Name:_________________________________________________          Date:____________________________________

Address:_______________________________________________          Date of Birth:______________________________

_______________________________________________          Phone:___________________________________

Contact Person:_______________________________________________________________________________________

Phone Number of Contact Person:_________________________________________________________________________

Medical Condition/Diagnosis:

___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

Medications:__________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

Primary Care Doctor:___________________________________________________________________________________

PayorSource:_________________________________________________________________________________________

Any person requiring Personal Care or Nursing Facility and who meets the defined requirements will be admitted to Loretto Motherhouse Infirmary, depending upon availability of a room and referral of a physician.  If a room is not immediately available, the person's name will be put on a waiting list. Priority will be given to Sisters of Loretto, then to persons from the outside community, depending upon the care needs of the individual, the referral of a physician, and the availability of space. App applications for admission to Loretto Motherhouse Infirmary will be given due consideration without regard to race, handicap, color, national origin, creed or ability to pay. A history and physical examination must be obtained and included as part of the resident's medical record. ADMISSION'S DEFINED REQUIREMENTS Persons needing Nursing Facility care must have needs in at least three activities of daily living areas--eating, dressing, grooming, transferring, bathing or ambulation.