Application for Admission

This Application Is For:
Area Applying For
Apartments:
Cottages:
Personal Care:
Personal Care Memory Support:
Skilled Care:
Skilled Care Memory Support:
How did you hear about St. Anne’s Retirement Community?:
Personal Information
Name:
Social Security Number:
Address:
Zip Code:
Email Address:
Cell Phone Number:
Home Phone Number:
Date Of Birth:
Place of Birth:
Gender:
Marital status:
Spouse’s Name:
Legal Information
Please choose the appropriate answer
Do you have an Advance Directive/Living Will?:
Do you have an Advance Directive/Living Will?:
Do you have a Durable Power of Attorney (POA) for Health Care?:
Do You Have a Will:
If yes, who is the Executor?:
Power of Attorney Information
Power of Attorney’s Name:
Phone Number:
Address:
Email:
Type of POA:
Children/Significant Other (Please list individuals in the order they should be contacted if unable to reach POA)
Full Name:
Relationship:
Cell Phone Number:
Home Phone Number:
Work Phone Number:
Address:
Email Address:
Full Name:
Relationship:
Cell Phone Number:
Home Phone Number:
Work Phone Number:
Address:
Email Address:
Full Name:
Relationship:
Cell Phone Number:
Home Phone Number:
Work Phone Number:
Address:
Email Address:
To Be Admitted From:
If Hospital – Name and Unit:
List Inpatient Stay Dates for Past Year (Hospital, Other Facility, Transitional Care, etc.):
Long Term Goal:
Health Insurance Information
Primary Health Insurance (Medicare, Advantage Plan, PPO)
Insurance Company:
Policy/ID Number:
Group Number( if applicable ):
Address:
Phone Number:
If Insurance is Medicare
Part A Effective Date:
Part B Effective Date:
Secondary Health Insurance
Carrier Name:
Insured Name:
Address:
Phone Number:
Policy ID Number:
Group Number ( If applicable ):
Annual cost for insurance is:
Do You Have a Long Term Care Insurance?:
Policy Number:
Do You Have Daily Personal Care Benefit?:
If Yes, please provide the carrier's name, address, and phone number:
Do You Have Daily Skilled Nursing Benefit:
If Yes,please provide the carrier's name, address, and phone number:
Do You Have Life Insurance:
If Yes, What is the company name?:
Face Value:
Cash Value:
Beneficiary:
Have you Applied for Medical Assistance?:
If Yes, When?:
MA Number:
Are You Veteran/ Spouse of Veteran?:
If Yes, Branch of Service:
Do You Take Prescription Medicines?:
What is the average monthly cost of it?:
Do you receive medication from VA?:
Do you have prescription card?:
Type:
Community Physician:
Phone Number:
Church Information
Church:
Phone Number:
Address:
Clergy:
Funeral Home Information
Funeral Home:
Phone Number:
Address:
Do you have a Burial Trust/Prepaid Funeral?:
Financial Information
Have you, or your Power of Attorney, received financial planning services?:
If yes, Name(s) of financial planning service employed by you, or your Power of Attorney:
Do you, or your Power of Attorney, have an attorney assisting you?:
If yes, Name of Attorney:
Have you disposed of, or gifted, real estate or personal property within the last 5 years?:
If Yes, list date and explain:
Assets, Liabilities, Income
Please identify if the asset, liability or monthly income
Please specify if the amount in each field is for individual, spouse, or joint (please list more than one option when appropriate)
Cash Type:
Cash Amount:
Checking:
Checking Amount:
Saving:
Savings Amount:
Certificates of Deposit:
Certificates of Deposit Amount:
Individual Retirement Account, 401k:
Individual Retirement Accounts, 401k Amount:
Mutual Funds:
Mutual Funds Amount:
Annuities:
Annuities Amount:
Stocks and Bonds:
Stocks and Bonds Amount:
Real Estate:
Real Estate Value:
Trust Accounts:
Trust Accounts Amount:
Loans to Others:
Loans to Others Amount:
Total Asset:
Total Asset Amount:
LIABILITIES
Rent Type:
Rent Amount:
Credit Card Debt Type:
Credit Card Debt Amount:
Other Debts Type:
Other Debt Amounts:
Mortgage Balance Type:
Mortgage Balance:
Total Liabilities Type:
Total Liabilities Amount:
Monthly Income
Social Security:
Pension Type:
Pension Amount:
Annuities Type:
Annuities Amount:
Investment Income Type:
Investment Income Amount:
Rental Income Type:
Rental Income Amount:
VA Benefits Type:
VA Benefits:
Total Income Type:
Total Income:
Real Estate Owned
Street Address:
City:
State:
Zip Code:
Estimated Value:
Mortgage Balance:
Other Asset:
Other Asset Type:
Fair Market Value:
Street Address:
City:
State:
Zip Code:
Estimated Value:
Mortgage Balance:
Other Asset:
Other Asset Type:
Fair Market Value:
Street_Address:
City::
State:
Zip Code:
Estimated Value:
Mortgage Balance:
Other Asset:
Other Asset Type:
Fair Market Value:
Conviction
Have you ever been convicted of a crime other than a summary offense?:
If Yes, What was the Date of the Conviction:
If Yes, Please describe the Conviction:
Agreement
I have applied for admission to St. Anne’s Retirement Comminuty. In doing so, I understand that St. Anne’s Retirement Community has a special obligation to clients, Residents and staff with respect to their personal property and safety. I hereby give St. Anne’s Retirement Community the right to make a thorough investigation into my previous employment, education, references, and character, and I release from all liability all persons supplying such information.
Check to Accept the Above Agreement:
Todays Date: