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CHECK OFF LIST

Resident Name: ____________________________________________

Medical Records #: ____________________________________________

Admission Date: ____________________________________________

I have received or verbally had the following explained to me:

Face Sheet
Open Admission Policy
Admission Contract 
Consent for Treatment
Physician Contact Information
Consent for Influenza Vaccine
Consent for Pneumococcal Vaccine
Durable Power of Attorney
Privacy Acknowledgement
Bill of Rights Pamphlet
Abuse Policy/Prohibition
Release of Information
Release of Medical Information

Bed Hold Policy
Smoking Policy
Privacy Phone
Consent for Photograph
Address Change Policy
Grievance Policy & Procedure
Patient Pay
Social Security Administration. Consent
Pension Consent
Resident Trust Fund Policy
Insurance Verification & Cards
Acknowledgement of Valuables
3rd Floor Stay Limitations


Responsible Party: __________________________________ Date: ___________


Facility Representative: ______________________________ Date: ___________

For further assistance, please feel free to contact (313)875-1263

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contact us

Lakeshore Healthcare Woodward Campus
9146 Woodward Ave., Detroit, Michigan 48202
Office: (313)875-1263 | Fax: (313)875-584


ADMINISTRATIVE OFFICE HOURS:

8:30 a.m. until 5:00 p.m.
 

Facility 24 Hours, family members may visit their loved ones at any time. However, we request that your visit not disrupt or disturb other residents.



 
 
CONTACT INFO:      

Corporate Office
7310 Woodward Ave. Suite 502
Detroit, Michigan 48202
Office: (313)483-3905
Fax: (313)420-0336

Cranbrook
5000 E. Seven Mile Road
Detroit, Michigan 48234
Office: (313)366-2900
Fax: 313-366-5357

Elmwood
1881 E. Grand Blvd.
Detroit, Michigan 48211
Office: (313)922-1600
Fax: 313-921-8380

Woodward
9146 Woodward Ave.
Detroit, Michigan 48202
Office: (313)875-1263
Fax: (313)875-5842

2014 by LHG, Michigan