The Gardens Assisted Living APPLICATION

The Gardens Assisted Living APPLICATION

Resident’s Name / First / Middle / Last / Marital status (circle one)
Single / Married / Divorced / Widow
Religion: / Present Location: / Birth date: / Age: / Sex:
/ / /  M /  F
Resident’s Billing Address: / Home Phone:
Emergency Contact Name: / Address: / Home Phone:
Work Phone:
E-Mail: / Cell Phone:
Financial Power of Attorney: / Address: / Home Phone:
Work Phone:
E-Mail: / Cell Phone:
Health Care Power of Attorney: / Address: / Home Phone:
Work Phone:
E-Mail: / Cell Phone:
Legal Guardian: / Address: / Home Phone:
Work Phone:
E-Mail: / Cell Phone:

INSURANCE INFORMATION

Medicare # / Social Security#
Medicaid # / Medicare Part D Prescription Drug Plan:
Coinsurance (MediGap/Supplemental) / Group # / Policy # / Phone # for Benefits Verification:
( )
Other Insurance: / Group # / Policy # / Phone # for Benefits Verification:
( )
Do you have Long-Term Care insurance? /  Yes /  No / Total $ value of Benefit: / $
Insurance Company / Group # / Policy # / Phone # for Benefits Verification:
( )

CONFIDENTIAL FINANCIAL DATA FOR PROSPECTIVE RESIDENT

Financial data is strictly confidential and may be required as a condition of admission. Data collected to advise residents’ if/when they may qualify for government assistance. This center is Medicare and Medicaid certified. Exact amounts are not required. Approximate totals are adequate for planning purposes.
At an average cost of $6500 per month for nursing care or $4000 per month for assisted living, if paying privately, how long would your private funds cover the cost of care?
 Less than 3 months /  3 to 6 months /  7 months to 1 year /  More than 1 year
Have you applied in person for Medicaid?  Yes Date: ______/______/______ No
If YES, what is the status of the application? /  Pending Medicaid #: ______/  Approved /  Denied /  Don’t Know
Approximate Monthly Income / Bank Account Information / Investment Information (ex. Stock, Bond, CD, 401k, IRA) / Other Assets (Approximate Value)
Social Security / $ / Checking Acct. Bank Name: / Type: / $ / Home / $
Pension/Retirement / $ / Approx. Checking Balance:
$ / Type: / $ / Other Real Estate / $
Other / $ / Savings Acct. Bank Name: / Type: / $ / Life Ins.w/cash Balance / $
Other / $ / Approx. Savings Balance:
$ / Type: / $ / Term life Death Benefit / $
1. Have you transferred any assets (i.e., gifts, real estate, bank accounts, etc.) to anyone in the last sixty (60) months (5 Years)?  Yes  No
If YES, then please provide the following information below
Name Transferred to: / Asset Transferred / Amount / Value / Date of Transfer
2. Have you created any trusts in the last sixty (60) months (5 years)?  Yes  No
Trustee Name / Type of Trust / Amount / Value / Date of Creation

CERTIFICATION

The undersigned persons represent(s) that the information contained on this application form and any attached documents are true to the best of his/her/their knowledge and belief. The undersigned persons understand the “THE CENTER” will rely upon such information, and agree that intentional misrepresentations or material omissions made by the undersigned persons in connection with this application may result in the denial of the application or future discharge of the resident.

The undersigned person(s) understand the “THE CENTER” may use or release this information in connection with providing care and/or receiving payment for providing care and services to the prospective resident. Such use or release of this otherwise confidential information is hereby authorized by the undersigned persons.

Photocopies of this release will be binding as the original.

The undersigned person(s) warrant that they can legally give the consent and authorizations made above.

______

Prospective Resident’s SignatureDate

If this application is not being completed by the prospective resident, then the person completing the application should sign below.

______

SignatureDate

______

OFFICE USE ONLY:
 Rehab Only /  Potential / ICF /  Potential AL