Admission agreement for a secured memory care unit covering dementia-specific care, behavioral support, secured environment disclosure, financial responsibility, and authorized representative designation.
The Memory Care Admission Agreement is a ready-to-use senior & elder care template you can send for signature in minutes. It is written for 2 signers (resident and facility) and, by default, expires 30 days after it is sent if left unsigned. It covers memory care, dementia, admission. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Memory Care Admission Agreement **Admission Date:** ___________ **Facility Name:** ___________ ("Facility") **Facility Address:** ___________ **Facility License Number:** ___________ **Memory Care Unit Name / Wing:** ___________ **Facility Phone:** ___________ **Resident:** ___________ ("Resident") **Resident Date of Birth:** ___________ **Resident Medicare Number (if applicable):** ___________ **Resident Medicaid Number (if applicable):** ___________ **Authorized Representative:** ___________ **Representative's Relationship to Resident:** ___________ **Representative's Legal Authority:** ___________ **Representative's Phone:** ___________ **Representative's Email:** ___________ The Facility and the Authorized Representative acting on behalf of the Resident (together, the "Parties") enter into this Memory Care Admission Agreement ("Agreement") as of the Admission Date above. ## 1. Diagnosis and Level of Care **Primary Diagnosis:** ___________ **Disease Stage at Admission:** ___________