Main Street Reservation Program -



		Job Openings & Descriptions
		Secure Application

Step 1. Please take a few moments to complete this brief application. (*) denotes a required field.

Name:		*

Today's Date:		*

Address:		*

Telephone:		*

Alternate Telephone:



Check the situation that best applies to you: *

	I am requesting a reservation following an upcoming surgery/medical procedure.

	I am requesting a reservation during a caregiver vacation/break.

	I am requesting a reservation due to other reasons.


Describe your situation:		*

Name of Primary Physician:		*



Fill out the following three fields if you chose the first situation (surgery/medical procedure):

Date of Surgery:

Hospital:

Name of Surgeon:



Fill out the following field if you chose the second situation (caregiver vacation/break):

Dates/Length of Vacation:



Insurance Information:

Medicare Number:		*

Other/Secondary Insurance Provider:		*

Policy Number:		*

Group Number:		*

Medicaid Number:		*

Name of Individual Requesting Information (if different than above):

Relationship to Patient:

Telephone:

Step 2: After we receive your information, our Admissions Director will contact you to arrange a convenient time to provide you with complimentary education related to your future stay at Main Street Care Center, including:

Accomodations & Amenities
Dining and Nutrition
Rehabilitative Therapies
Social Events & Activities
Physician Services
Medical Specialties

Step 3: Tours are welcome any time including evenings and weekends. It is our pleasure to meet you, introduce you to our exceptional team and to experience the Main Street Care Center difference.

Please bring copies of the following documents with you:

Medicare Card
Insurance Cards
Medicaid Card
Power of Attorney
Social Securaty Card
Surgery Information
Living Will
Emergency COntact Information

If you do not have time to make copies, just let us know. We will be glad to make copies of your orgiinal documents and provide you with an extra set for your files.

Step 4: When transferring directly from the hospital setting to Main Street Care Center, you can count on a personal visit by our Nurse Case Manager. She will provide you with additional education, answer any last minute questions and serve as a liaison in promoting a smooth and stress-free transition for you and your family.