Admission Acceptance

Admission Process and Checklist

Documentation Required Before Admission

• Proof of Maryland residency
• Proof of honorable discharge (DD Form 214 or equivalent)* - *If the applicant does not have a copy of his DD Form 214, the applicant may get a copy of the form to request the document. It takes approximately 6 weeks to receive the new DD Form 214.
• Proof of disability if under age 62.
• Have the applicant's personal physician complete the medical forms necessary for admission. If the applicant has been hospitalized, the applicant needs to supply his medical records from the hospital.
• Proof of income

Assisted Living Requirements

• The applicant must have a complete physical verifying that he has the mental and physical ability to perform the following:
• Perform routine and daily personal functions - dress and feed himself, make his own bed and keep his room clean.
• Make his way to and from the first floor dining area.
• Control body eliminations (either naturally or by prosthesis).
• Make rational and competent decisions as to the desire to remain or leave Charlotte Hall

Skilled Nursing Care

The applicant must have his physician verify that he does not require medical, surgical and nursing care beyond the capabilities of the facility. If the applicant is admitted directly from a long-term health care facility, please provide the following information:

• Current medical findings
• Diagnosis and prognosis
• Medical rehabilitation goals
• A summary of the course of treatment followed in the hospital or other health care facility
• Physician orders for immediate care

If the applicant moves to Charlotte Hall directly from home, please supply the following medical information:

• Current (within 30 days) medical findings
• Diagnosis and Prognosis
• Medical rehabilitation goals
• Physician orders for immediate care

To qualify for admission to our Alzheimer's Unit, the applicant must meet all of the following criteria:

• Have a diagnosis of Alzheimer's disease or related dementia as confirmed by his personal physician.
• Require the security of a locked medical unit to prevent wandering
• Require limited assistance in ADL function with direct supervision and assistance
• Be capable of participating in the activities on this Special Care Unit

For Physician

• "Physician Certification Related to Medical Condition" Form
• Healthcare Practitioner's Physical Assessment (Assisted Living only) Form 4506
• Maryland Medical Assistance Medical Eligibility Review Form (Long-term Care only) Form 3871
• VA Form10-10SH
• Department of Health and Mental Hygiene ID Screen (Long-term Care only) Form 4345
• Physicians Orders for your immediate care (Long-term Care only)
• Chest X-ray

***All medical forms must be dated within 30 days of admission date***

Send your completed application to:

Or feel free to drop the application off personally and speak with our Admissions Coordinator to answer any questions you may have regarding admission to our facility.