Alarmed entry and exitsRequirements to notify staff when leavNo locks on resident room doorsAny other security measures your facility utilizess and the common areas of the facility e staff has the rig ID: 891080
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1 10. This facility follows the following
10. This facility follows the following security [Alarmed entry and exits [Requirements to notify staff when leav [No locks on resident room doors [Any other security measures your facility utilizes s and the common areas of the facility. e staff has the right to enter your room; however, the staff will make every effort to be respectful of your privacy and will from t
2 he facility for a hospitalization, vacat
he facility for a hospitalization, vacation, or other reason, the facility will hold your bed, provided: [facility policy on payment for periods of absence including any reduction in fee the facility may provide In the event of an emergency situation which could maat the facility, the facility will make arrangements to temporarily relocate you to: [facilitys plan fo
3 r emergencies dent rules of the facility
r emergencies dent rules of the facility are attached to this agreement ing this agreement, you have indicated acknowledgment and receipt of the resident The following special [admission ] and/or [discharge ] conditions apply: [Include as necessary]. Revised 2/18/09 MISCELLANEOUS PROVISIONS [Facility, you, or your responsible party including equipment and sup
4 plies not [Facility, you, or your respon
plies not [Facility, you, or your responsible party ] is responsible for monitoring your health The facility [will/will not ] handle your finances for you if you are unable. [If facility does handle finances, describe policy here.] the facility will pack up your belongings and safely store them for 30 days. If you or your family has not retrieved them within 30 IN WIT
5 NESS WHEREOF, THE PARTIES HAVE EXECUTED
NESS WHEREOF, THE PARTIES HAVE EXECUTED THIS AGREEMENT on WITNESS: [NAME OF FACILITY _______________________________ _____________________________________ By: [SIGNATURE Name: [PRINTED NAME Title: _______________________________ WITNESS: RESIDENT or RESPONSIBLE PARTY: ________________________________ ___________________________________