Application for Admission

ADMISSION APPLICATION

Please complete an application for each person.
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 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)
Child/Significant Other #1:
Relationship:
Cell Phone Number:
Home Phone Number:
Work Phone Number:
Address:
Email Address:
Child/Significant Other #2:
Relationship:
Cell Phone Number:
Home Phone Number:
Work Phone Number:
Address:
Email Address:
Child/Significant Other #3:
Relationship:
Cell Phone Number:
Home Phone Number:
Work Phone Number:
Address:
Email Address:

Admission Details:

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:

Long Term Care Insurance

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:

Life Insurance

Do You Have Life Insurance:
If Yes, what is the company name?:
Face Value:
Cash Value:
Beneficiary:

Medical Assistance (MA)

Have you Applied for Medical Assistance (MA)?:
If Yes, when?:
MA #:

Veteran Status

Are You Veteran or Spouse of Veteran?:
If yes, branch of Service:

Prescription Medicine

Do you take prescription medicines?:
What is the average monthly cost of it?:
Do you receive medication from VA?:
Do you have a prescription card?:
Type or prescription card:

Community Physician

Community Physician:
Phone Number:

Church Information

Church's Name:
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, list the name(s) of the 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

Please supply copies of your latest statement for the assets listed below.
Please specify if the amount in each field is for individual, spouse, or joint (please list more than one option when appropriate)
Cash:
Cash Assets are:
Checking Account Value:
Checking Account(s) are:
Savings:
Savings are:
Certificates of Deposit:
Certificates of Deposit are:
Individual Retirement Accounts (IRAs) & 401k:
IRA / 401k are:
Mutual Funds:
Mutual Funds are:
Annuities:
Annuities are:
Stocks and Bonds:
Stocks and Bonds are:
Real Estate:
Real Estate is:
Trust Accounts:
Trust Accounts are:
Loans to Others:
Loans to Other are:
TOTAL ASSETS:
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
Property 1: Street Address:
City:
State:
Zip Code:
Estimated Value:
Mortgage Balance:
Other Asset:
Other Asset Type:
Fair Market Value:
Property 2: Street Address:
City:
State:
Zip Code:
Estimated Value:
Mortgage Balance:
Other Asset:
Other Asset Type:
Fair Market Value:
Property 3: Street Address:
City:
State:
Zip Code:
Estimated Value:
Mortgage Balance:
Other Assets
Other Asset:
Other Asset Type:
Fair Market Value:
I represent the resources listed above are and will remain available for payment of services I may receive at St. Anne's Retirement Community:

Criminal Background

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 Community. 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 releasee from all liability all persons supplying such information. The investigation is not limited to the above, and criminal checks, both State and Federal, can be required. I authorize all public officials or persons involved in reference for admission to furnish information necessary for residency at St. Anne’s Retirement Community. Records obtained will be confidential.

I hereby certify that the information and financial statements provided in this application are correct and complete to the best of my knowledge. I understand that any misrepresentation could result in the forfeiture of my application or status as a resident of St. Anne’s Retirement Community, Inc. I understand that this application does not obligate St. Anne’s Retirement Community, Inc. in any way and is submitted to be placed on file, and that the above information is strictly confidential.

In the event a resident becomes a danger to themselves and/or others, as in the judgment of the attending physician and Administrator, to jeopardize the health and/or safety of other residents or constitutes a hazard to himself/herself, St. Anne’s Retirement Community shall cooperate with the relative or responsible party in finding the most appropriate placement for the Resident.
Check to Accept the Above Agreement:
Todays Date: