Apply for Residence

Dear Applicant:

Thank you for considering Napoleon Care Center. Below, you will find an application form and an authorization for release of medical information form. If an advance directive is in place, also include a copy.  Following receipt of these forms, I will be in contact with you.

Our facility offers skilled nursing care.  Admissions are conducted by matching an applicant’s needs with the most appropriate opening.

All applicants must also have approval for admission from First Mental Health, Inc. prior to admission.  They must be determined to have actual need for nursing facility care (PASARR Screening).  Upon receiving all medical information from your physician, I will submit this information to First Mental Health, Inc.

We are Medicare/Medicaid certified as explained in the enclosed brochure and thus bound to the case mix classification system requiring us to charge depending on the amount of nursing care needed.  The current rates are also enclosed.

If you would like to see our facility, I would be happy to provide you with a tour and answer any questions you may have.  Feel free to call for an appointment.  Thank you again for contacting Napoleon Care Center.

Sincerely,

Ronda Erbele, LSW
Connie Weigel, SSD

 

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FOR NURSING HOME ADMISSION

Apply for Residence

  • I hereby request and authorize:

  • To release to:

    Ronda Erbele, LSW (Releasee) or Connie Weigel, SSD (Releasee) Napoleon Care Center
    PO Box 90
    Napoleon, ND 58561 The following information is requested:

    1. History and physical that includes complete medical history, review of all body systems, specific evaluation of individual’s neurological system in all areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes. If there are abnormal findings, specialist’s evaluations are needed.

    2. Comprehensive drug history.

    3. The completion of the attached form: ND Level I screening and Level of Care Determination.

    4. Recent medical problems/surgeries if not addressed in history and physical.

    Releasor, its agents and its employees, are hereby relieved any responsibility or liability that may arise from the release of reproduction of such records and/or information.

    Releasee, its agents and its employees, are hereby authorized to obtain, inspect and reproduce such records and/or information and are hereby relieved of any responsibility or liability that may arise from such actions.

    This authorization to Releasor and Releasee and this waiver of liability includes, but is not limited to, charts, x-ray, photographs, motion picture films, reports, information, papers, writings, and records concerning both the patient’s physical and mental/emotion condition, whether Releasor now has same or makes or obtains them in the future.
  • Application for Admission

  • In order for us to process the application, it will be necessary for you to fill in all the blanks with the information requested:
  • Complete the next 4 items whether individuals are living or deceased:

  • Family members or friends to be contacted in case of emergency:

  • Primary Medical Problem:

  • Personal care needs

  • Treatments

  • Labwork / X-rays:

  • Mental condition

  • Person completing this application.

Napoleon Care Center
PH: (701) 754-2381
311 East 4th Street
Napoleon, ND 58561