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Senior Residential Facility in Bedford, Ohio

APPLICATION Materials

Applicant’s Consent to Release Medical Information

I hereby authorize any physician, clinic or hospital to answer fully any request from Light of Hearts Villa for medical or psycho-social information concerning me as an applicant or while I am a Resident at Light of Hearts Villa.

"*" indicates required fields

Resident Name*
MM slash DD slash YYYY
MM slash DD slash YYYY

Application for Admission – Part 1

Emergency Contact Information
Resident Information

(Please Print)

First Name*
M.I*
Last Name*
Preferred Name/Nickname
MM slash DD slash YYYY
Gender*
Marital Status
CURRENT ADDRESS*
Primary Doctor
Name*
ADDRESS*
Other Doctor or Specialist
Name
ADDRESS
Dentist
Name*
ADDRESS*
Primary Hospital
Hospital Name*
ADDRESS*
Funeral Home
Funeral Home Name
ADDRESS
Other Doctors’ Notes and Contact Information:

Names & Relationship of Immediate Contact(s)

If there is a legal guardian, please list the information and attach documentation to this form.

Name of Guardian
ADDRESS
Power of Attorney

Contact #1 will be the first contacted in case of an Emergency.

Contact #1
Billable Party:*
Durable POA:*
Healthcare POA:*
Name:
ADDRESS
Contact #2
Billable Party:
Durable POA:
Healthcare POA:
Name:
ADDRESS
Contact #3
Billable Party:
Durable POA:
Healthcare POA:
Name:
ADDRESS

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NEWS & updates

Light of Hearts Villa Celebrates Deficiency-Free Survey

January 4, 2024

Light of Hearts Villa, a senior living community in Bedford, Ohio, received zero deficiencies during their annual state survey this past month. An accomplishment that is not easily attainable in the highly regulated world of assisted living. But what exactly does having “zero deficiencies” mean?

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Light the Way Gala 2023

September 30, 2023

Our annual Light the Way Gala celebrated an incredible evening of generosity and support, raising over $120,000 for the Sister Helen T. Scasny, SC Benevolent Fund. This sold-out event on September 29, attended by over 250 people, illuminated the unwavering commitment of the community to the mission of Light of Hearts Villa.

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283 Union Street | Bedford, Ohio 44146

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© 2024 Light Of Hearts Villa. All Rights Reserved. | Website by HLJ Creative
© 2024 Light Of Hearts Villa. All Rights Reserved. Website by HLJ Creative