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Admission Application

There are currently two options for submitting an Application for Admission. The first option is to complete the online application below. We will call to fill in a few additional items after your online submission. Please note that the online application must be completed and submitted in one sitting and cannot be saved when partially completed.

The second option is to download and print a copy of the application. If you choose this option, please click on the link below to download the Admission Application.

Download Admission Application

 

Online Admission Application:

    Your Name (required)

    Your Email Address (required)

    Your Phone Number (required)

    Date of Birth (required)

    Select Gender (required)

    Address (required)

    Select Marital Status (required)

    Name of Spouse

    If deceased, Date of Spouse's Death

    Veteran or Widow of Veteran
    YesNo

    Date of Service

    Primary Insurance and ID #

    Supplemental Insurance and ID #

    Religion

    Preference of Funeral Home

    Financial Information

    All assets solely and jointly owned shall be reported.

    Have you or your spouse closed, given away, sold, or transferred any assets within the last 5 years?
    YesNo

    Explain

    Monthly Income Type and Amount

    Real Estate Owned and Titled in Names

    Bank & Other Assets and Total Value

    Life Insurance and Value

    Primary Care Physician

    Level of Care Assessment Completed by Area Agency of Aging
    YesNo

    Secured Unit Needed
    YesNo

    Additional Contact Information

    1. Power of Attorney/Responsible Party

    Name (required)

    Address (required)

    Telephone (Home, Work, and Cell) (required)

    Email Address (required)

    2. Secondary Contact

    Name (required)

    Address (required)

    Telephone (Home, Work, and Cell) (required)

    Email Address (required)

    Send a brochure to my email address

    Contact Us

    Office Hours:

    Our administration offices are open Monday through Friday, 8:00 a.m. – 4:30 p.m.

    Mailing Address:

    Cedar Haven Healthcare Center

    590 South 5th Avenue

    Lebanon, PA 17042-9154