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(717) 274-0421

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

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

“Thank you for your interest in Cedar Haven. Please do not hesitate to contact us with your questions or to schedule a tour of our facility.”

Patti Malay, Director of Admissions

Cedar Haven Healthcare Center  |  590 South 5th Avenue  |  Lebanon, PA 17042-9154  |  (717) 274-0421  |   pmalay@cedarhaven.healthcare

© 2015 Cedar Haven | We subscribe to a non-discrimination policy | We follow guidelines set forth by the Americans with Disabilities Act | Equal Opportunity Employer