Form PCHB2 "Personal Care Home Benefit (Pchb) Confirmation of Admission Form" - Saskatchewan, Canada

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Personal Care Home Benefi t (PCHB )
Confir mation of Admission Form
This form is to be completed when a resident wishes to apply for the Personal Care
Home Benefit program and the resident was admitted to the home within the past 60
days and is occupying a licensed personal care home space.
This form is not required for a person who has lived in the home for more than 60 days.
_______________________________________
___________________________
Name of Personal Care Home (print)
Personal Care Home Licence Number
_______________________________________
___________________________
Name of Resident (print)
Date of Admission (dd/mm/yyyy)
This is to confirm that the above named person is currently a resident of a licensed
space in the Personal Care Home and was admitted to the home on the date shown
above.
______________________________
_______________________ _____________
Name of Personal Care Home Operator (print)
Signature
Date (dd/mm/yyyy)
Form PCHB 2 (2012)
Personal Care Home Benefi t (PCHB )
Confir mation of Admission Form
This form is to be completed when a resident wishes to apply for the Personal Care
Home Benefit program and the resident was admitted to the home within the past 60
days and is occupying a licensed personal care home space.
This form is not required for a person who has lived in the home for more than 60 days.
_______________________________________
___________________________
Name of Personal Care Home (print)
Personal Care Home Licence Number
_______________________________________
___________________________
Name of Resident (print)
Date of Admission (dd/mm/yyyy)
This is to confirm that the above named person is currently a resident of a licensed
space in the Personal Care Home and was admitted to the home on the date shown
above.
______________________________
_______________________ _____________
Name of Personal Care Home Operator (print)
Signature
Date (dd/mm/yyyy)
Form PCHB 2 (2012)