Cordell Christian Home - New Admissions

New Admissions

If you or a loved one would like to become part of the CCH family, simply fill out the following form and submit it! Then we will contact you as soon as possible.

Admission Inquiry

Name of Possible Admit:
Gender:
Transfer From:
Reason for Transfer:
Marital Status:
Type of Admission:
Diagnosed with a Mental Disorder?
If "Yes," please state diagnosis:
Insurance:	Medicare Medicaid Private Insurance
Smoker?
Preferred Admission Date:
Name and Address of Physician:
Has Possible Admit had any hospital stays within the last 3 months?
If "Yes," please state the name and address of the hospital.:
Any prior stays in a nursing home?
If "Yes," please state the name and address of the nursing home.:

Personal Contact Information

Your Name:
Relationship to Possible Admit:
Address:
City:
State:
Zip:
Phone Number:
E-mail Address:

Still trying to make the "Nursing Home"
decision?

Here are some helpful links!

www.longtermcareliving.com
/pdf/making_transition.pdf

http://www.geocities.com/
~elderly-place/nursinghome.
html

http://www.agingcare.com/

1400 N. College St. Cordell, OK 73632 - (580) 832-3371