St Ann's Community Long-Term Care Application

NOTE: All fields with an asterisk (*) are required

Name * First Last
Social Security Number *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Telephone # * - (###) - ### ####
County of Residence *
DOB * / MM / DD YYYY
Marital Status * Married Widowed Divorced Single
Sex * M F
Religion
Place of Worship
U.S. Citizen * Yes No
If naturalized citizen, date / MM / DD YYYY
Occupation *
Employer *
Are you currently working? * Yes No
Is your spouse currently working? * Yes No
Are you a veteran? * Yes No
Is your spouse a veteran? * Yes No
Current location of Applicant *
If applicant is currently hospitalized or has been hospitalized within the past 30 days, please complete the following:
Name of Hospital
Dates of stay
Reason for Hospitalization
Has the applicant had a previous nursing facility stay? Yes No
If yes, please give the name of the facility and dates of stay
Have Advanced Directives been established? MOLST Living Will DNR Health Care Proxy
Please provide a copy of the Advanced Directives at the time of admission.
Name of Funeral Home *
Telephone # * - (###) - ### ####
Has a pre-need burial account been established? * Yes No
Is this account irrevocable? * Yes No
Insurance Coverage for Applicant: Please provide a copy of all cards (both sides)
Medicare *
Part A * Yes No
Part B * Yes No
Medicaid *
County *
Do you have a Medicaid Managed Long Term Care Plan? (ie. Fidelis, I-Circle) * Yes No
If yes, which plan?
Case Manager Name * First Last
Case Manager Number * - (###) - ### ####
Health Insurance *
Case Worker Name * First Last
Case Worker Number * - (###) - ### ####
Other Insurance *
Medicare D Plan (prescription plan) *
Long Term Care Insurance *
SNF daily rate *
Lifetime Benefit *
NYS Partnership Plan *
Primary Contacts: Please list in order to be contacted (Use a separate sheet, if necessary)
Name * First Last
Relationship *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home phone * - (###) - ### ####
Cell phone * - (###) - ### ####
Work phone * - (###) - ### ####
Email address *
Power Of Attorney * Yes No
Health Care Agent * Yes No
Name * First Last
Relationship *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home phone * - (###) - ### ####
Cell phone - (###) - ### ####
Work phone - (###) - ### ####
Email address *
Power Of Attorney * Yes No
Health Care Agent * Yes No
Fiscal Agent: (manages financial obligations for applicant)
Name of Power of Attorney/Fiscal Agent * First Last
Relationship *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home phone * - (###) - ### ####
Cell phone - (###) - ### ####
Work phone - (###) - ### ####
Email address *
Has a conservator/guardian been appointed? (Please provide a copy) * Yes No
Have you gifted or transferred anything out of your name, money or property, greater than $2,000? * Yes No
If yes, please explain and provide dates of transfer
Have you given away any cash, or sold/transferred any cash, real estate, income or personal property in the past or created a trust in the past 60 months? * Yes No
If yes, please explain
Have you consulted with an attorney or financial advisor regarding payment for nursing home care? * Yes No
If yes, please provide name First Last
If yes, please provide number - (###) - ### ####
Financial Information – If married, please include financial information for spouse
Monthly
Applicant Salary * $ . Dollars Cents
Spouse Salary $ . Dollars Cents
Applicant Social Security *
Spouse Social Security
Applicant Retirement Pension *
Spouse Retirement Pension
Applicant Veteran's Benefit *
Spouse Veteran's Benefit
Applicant Interest/Dividends *
Applicant Other *
Spouse Other
Applicant Total Monthly Income * $ . Dollars Cents
Assets
Life Insurance (cash value) * Yes No
Life Insurance Amount (cash value) * $ . Dollars Cents
Checking Account * Yes No
Checking Account Amount * $ . Dollars Cents
Name of Bank *
Savings Account * Yes No
Savings Account Amount * $ . Dollars Cents
Name of Bank *
Certificates of Deposit
Certificates of Deposit Amount * $ . Dollars Cents
In whose name is this asset held? * First Last
Stocks
Stocks Amount * $ . Dollars Cents
In whose name is this asset held? * First Last
Annuities
Annuities Amount * $ . Dollars Cents
In whose name is this asset held? * First Last
Are you drawing income? * Yes No
Does this have cash value? * $ . Dollars Cents
Money Market
Money Market Amount * $ . Dollars Cents
In whose name is this asset held? * First Last
Bonds
Bonds Amount * $ . Dollars Cents
In whose name is this asset held? * First Last
IRAs/401K/403B
IRAs/401K/403B Amount * $ . Dollars Cents
In whose name is this asset held? * First Last
Total Assets * $ . Dollars Cents
Real Estate
Does the Applicant own a home? * Yes No
Spouse, disabled adult, or child in the home? * Yes No
Please list all Real Estate assets. Please include property and building address as well as approximate value *
Liabilities (example: mortgage, liens, credit cards, loans) and their amount *
Total Liabilities * $ . Dollars Cents
Please provide additional financial information that may be pertinent to this application *
Additional information/comments, which may be helpful in processing this application: *
By checking the box below, I hereby certify and affirm that all of the information contained in this Financial Statement is complete, accurate and truthful to the best of my knowledge. * I Agree
Signature of Applicant/Responsible Party * First Last
Date * / MM / DD YYYY
Relationship *
St. Ann’s Community respects the rights of all people and applications are considered without regard to race, creed, color, age, gender, marital status, disability, sexual orientation, national origin, or sponsor.
This Community is a smoke-free campus.

CONSENT FOR RELEASE OF INFORMATION TO ST. ANN’S COMMUNITY
Name * First Last
DOB * / MM / DD YYYY
I hereby expressly authorize and request that each of the following persons, agencies, and organizations give full detailed, and relevant information regarding me to St. Ann’s Community:

1. Social Security Administration
2. Any and all physicians, dentists, social workers, psychologists, nurses, technicians, clinics, hospitals, and psychiatric facilities, Nursing Homes, Assisted Living Facilities where I have been a patient.
3. Any and all banks and bankers which now hold or heretofore held my funds; and all persons, firms, or corporations which hold my funds or funds payable to me
4. Any and all persons, firms, or corporations which hold my funds or funds payable to me
5. Any and all insurance companies by which I am an insured or which hold my funds or funds payable to me
Signature of Applicant or Responsible Party * First Last
Date * / MM / DD YYYY
Relationship to Applicant *
Statement Regarding Monthly Income Amounts
I, as Power of Attorney or as the person responsible for * First Last
Financial affairs, agree to sign all documentation required to change the address on any and all monthly social security or pension payments so that these payments will be sent directly to the SNF where I am admitted to be used for the resident’s cost of care. I agree to sign the required paperwork on the resident’s day of admission for the Nursing Home.

I also agree that beginning with the first month of admission and continuing until the change of address has been implemented by the payer, to submit upon receipt, all funds received on behalf of the resident to the Nursing Home to pay for the resident’s care. I understand that I am not to submit payments in excess of the resident’s cost of care.

If the resident is eligible for Medicaid, I understand that the $50.00 allowed for the resident’s personal needs, may either be deposited into an individual fund for the resident or maintained at the Nursing Home or returned to me. If the resident is not eligible for Medicaid, the entire payment will be applied to the resident’s bill unless otherwise directed.

I understand that all the above referenced payments will be applied against the resident’s account and will appear on the monthly statements that I receive from the Nursing Home.
Responsible Party * First Last
Date * / MM / DD YYYY
FISCAL AGENT AGREEMENT
This Agreement made effective * / MM / DD YYYY
by and between St. Ann's Community ("St. Ann's") and * First Last
residing at *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
(hereinafter "Fiscal Agent"), as an individual with legal access to funds or resources of (hereinafter "Resident") * First Last
WHEREAS, St. Ann’s is reviewing whether to admit Resident and to provide the services specified in the Admission Agreement; and

oWHEREAS, Fiscal Agent has legal access to the assets, income, and other resources of the Resident; and

WHEREAS, Fiscal Agent agrees and acknowledges that St. Ann’s will rely on the Fiscal Agent’s agreements contained herein.

oNOW, THEREFORE, for good and valuable consideration, the parties hereby agree as follows:

1.The above recitals are incorporated herein and made a part hereof.

2.Fiscal Agent hereby agrees to promptly and timely assist the Resident in fulfilling his/her responsibilities under the Admission Agreement.

3.Fiscal Agent hereby certifies that the information set forth in the application is true, complete and accurate to the best of Fiscal Agent’s knowledge, and Fiscal Agent hereby agrees to promptly and timely cooperate with St. Ann’s to obtain payment from the Resident’s assets, income and resources for all of Resident’s charges, and to assist Resident to make all payments due in accordance with the terms of the Admission Agreement. Fiscal Agent is not required and is not being asked, to pay for the Resident’s care from Fiscal Agent’s assets or income.

4.Fiscal Agent agrees that all of Resident’s assets, income, Medicare and insurance benefits and other resources will be used to timely pay all of Resident’s charges incurred at the St. Ann’s.

5.Fiscal Agent agrees that Fiscal Agent will make payment to the St. Ann’s of all charges, fees and expenses, payments for physician visits and all properly authorized additional charges and rate increases from the Resident’s assets, income, Medicare and insurance benefits and other resources.

6.Fiscal Agent agrees that if the Resident becomes eligible for Medicaid benefits, Fiscal Agent shall promptly and timely initiate, complete and file an application for Medicaid benefits and all subsequent recertification’s that may be required to ensure uninterrupted Medicaid benefits for Resident.

7.If Fiscal Agent is the attorney-in-fact for the Resident through a power of attorney, Agent appoints St. Ann’s as limited Power of Attorney for Resident for the purpose of obtaining bank and financial information necessary to complete Resident’s Medicaid application.

8.If the Resident becomes Medicaid eligible, the Fiscal Agent agrees to assure that St. Ann’s is paid monthly that portion of the monthly Medicaid rate (the “NAMI” amount) which the Medicaid agency directs the Resident to pay towards the Resident’s cost of care.

9.Fiscal Agent personally agrees that if he/she is representative payee or otherwise receives or controls any of Resident’s NAMI, and if he/she or Resident fails to pay such NAMI in a timely manner, St. Ann’s is hereby directed to apply for and become representative payee of the Resident to provide for the direct deposit of Social Security benefits upon the filing of the Resident’s Medicaid application.

10.Fiscal Agent agrees that in order to assist Resident in meeting his/her obligations for any NAMI specified by DSS, if he/she or Resident fails to pay such NAMI in a timely manner, St. Ann’s is directed to apply for and become representative payee of the Resident with respect to Resident’s pension.

11.Fiscal Agent agrees, warrants and covenants that all of Resident’s assets, income, insurance benefits and all other resources as disclosed to St. Ann’s prior to and/or at the time of admission shall be used to satisfy in full all future bills from St Ann’s and shall not be otherwise used, transferred, diverted, gifted, loaned, or pledged to any other person or party.

12.Fiscal Agent represents and warrants that no transfer of Resident’s assets, income, Medicare or insurance benefits or other resources, has taken place or will occur which would prevent Resident from qualifying for Medicaid benefits. If a transfer is made and if it is later determined that such a transfer results in a full or partial denial of Medicaid benefits, Fiscal Agent shall take any and all steps necessary to immediately return such assets, income, benefits or other resources to Resident’s use in order for Resident to fully qualify for Medicaid.

13.Fiscal Agent expressly understands that St. Ann’s is relying upon each and every statement, representation, covenant and warranty by Fiscal Agent in this Agreement and in the financial statements presented by Resident and Fiscal Agent prior to and/or upon admission and, in light thereof, Fiscal Agent expressly represents and warrants the truthfulness, accuracy and completeness of each of the statements made herein.
Date * / MM / DD YYYY
Fiscal Agent (This is an agreement between you and St. Ann’s. Please sign as yourself; do not sign as POA) * First Last
Date * / MM / DD YYYY
St. Ann's Representative * First Last

St Ann's Community Long-Term Care Application

St Ann's Community Long-Term Care Application

If applicant is currently hospitalized or has been hospitalized within the past 30 days, please complete the following:

Please provide a copy of the Advanced Directives at the time of admission.

Insurance Coverage for Applicant: Please provide a copy of all cards (both sides)

Primary Contacts: Please list in order to be contacted (Use a separate sheet, if necessary)

Fiscal Agent: (manages financial obligations for applicant)

Financial Information – If married, please include financial information for spouse

Monthly

Assets

Certificates of Deposit

Stocks

Annuities

Money Market

Bonds

IRAs/401K/403B

Real Estate

Statement Regarding Monthly Income Amounts

FISCAL AGENT AGREEMENT