Admissions

As we turn the pages of our lives – growing up, working, experiencing loves and losses, raising our own children – we all experience times when we need a little extra help. At Colonial Health and Rehab, we have created an environment which combines and celebrates these memorable aspects of life and creates new experiences for you… experiences set in a comfortable, home-like setting which provides security and a variety of life-enriching activities.

Your Name:
Address:
City:
State:
Zip:
Telephone:
Email Address:
   
Relationship to resident:
Resident Name:
Gender:
Date of Birth:
Type of Care:
How Soon:

Immediate
Less Than 1 Month
Less than 6 Months
More than 6 Months
Unsure

Reason for admission:

Colonial Participates with Medicare/Medicaid, Aetna, Anthem Blue Cross, Private Pay, Medicaid Pending

Primary Insurance:
Secondary Insurance:
Where is the resident currently?
Preferred physican:

Dr. Alessandro
Dr. Habashy
Dr. Howe
Dr. Wilcon
Dr. Catsam

Acknowledgement (Click all to Agree)
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION IN CONNECTION WITH ELIGIBILTY FOR ADMISSION AND CONTINUED STAY AT COLONIAL HEALTH & REHAB CENTER OF PLAINFIELD, LLC

To: All providers of medical and dental services or supplies and their representatives, the Medical Information Bureau, Inc. or other organizations, all insurers, medical or hospital service plans, prepaid health plans.

For purpose of determining eligibility for admission and continued optimal medical care, I authorize you to furnish Colonial Health & Rehab center of Plainfield, LLC or its representatives performing business or legal functions, any information available about my medical history, condition and treatment.

I authorize Colonial Health & Rehab Center of Plainfield, LLC to re-disclose such information to an attending physician for treatment purposes and to any person who has an authorization specifically permitting the re-disclosure, and as may be permitted or required by law.

I hereby authorize Colonial Health & Rehab Center of Plainfield, LLC to disclose medical information to Medicare, insurance carriers, and other third party payor as is necessary and/or required by law to facilitate payment of claims in my behalf. I further authorize payment to be made directly to Colonial Health & Rehab Center of Plainfield, LLC for the services provided.

I agree that this authorization is valid throughout my stay at Colonial Health & Rehab Center of Plainfield, LLC.
I know that I have a right to ask for and receive a copy of this authorization.

  All Fields are required!

Admissions

If you're interested in learning more about programs and services, please click here

Visiting Hours

Our visiting hours are from 10 AM to 8 PM

Insurance Providers Accepted