A Patient Review Instrument (PRI) completed by the hospital or the County Health Department.
A copy of your Health Insurance, Medicare, and/or Medicaid Card
Power of Attorney or other Health Care Directives
Application Request
Along with a completed application, please provide us with the following documents:
|
A Patient Review Instrument (PRI) completed by the hospital or the County Health Department. |
|
A copy of your Health Insurance, Medicare, and/or Medicaid Card |
|
Power of Attorney or other Health Care Directives |
For further information or to receive an application contact us at ccnh@co.clinton.ny.us. When requesting an application, please include your name, address, city, state, zip code, and phone number.
You may also download an application by clicking on one of the icons below:
Nursing
Home Admission Application.doc (Word
97 Format) |
 Nursing
Home Admission Application.pdf |
Please complete the application and return to the Nursing Home.
Thank you for your interest in the Clinton County Nursing Home.