Admission and financial responsibility agreement for placement in a skilled nursing facility, covering care plan, rates, discharge rights, and resident rights under federal and state law.
The Skilled Nursing Facility 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 skilled nursing, admission, long term care. 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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# Skilled Nursing Facility Admission Agreement **Admission Date:** ___________ **Facility Name:** ___________ ("Facility") **Facility Address:** ___________ **Facility License Number:** ___________ **Facility Phone:** ___________ **Resident:** ___________ ("Resident") **Resident Date of Birth:** ___________ **Resident Medicare Number (if applicable):** ___________ **Resident Medicaid Number (if applicable):** ___________ **Responsible Party / Authorized Representative (if any):** ___________ **Representative's Legal Authority:** ___________ The Facility and the Resident (or the Resident's Authorized Representative acting on the Resident's behalf) (together, the "Parties") enter into this Skilled Nursing Facility Admission Agreement ("Agreement") as of the Admission Date above. ## 1. Purpose of Admission The Resident is admitted to the Facility for the following primary purpose: **Level of Care:** ___________ **Primary Diagnosis / Reason for Admission:** ___________ **Anticipated Length of Stay:** ___________ ## 2. Individualized Care Plan Within 14 days of admission (or as required by applicable law), the Facility shall develop a written Individualized Care Plan ("Care Plan") for the Resident in collaboration with the Resident (to the extent the Resident has capacity), the Resident's family or authorized representative, the attending physician, and the interdisciplinary care team. The Care Plan shall address medical, nursing, rehabilitative, nutritional, social, and recreational needs, and shall be updated at each reassessment period or following a significant change in condition.