St. Ann's Transitional Care Application

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

Demographics
Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Date of birth * / MM / DD YYYY
Social Security Number *
Phone * - (###) - ### ####
NY State Resident * Yes No
If no, state of residence
Gender * Male Female
US Citizen * Yes No
If no, country
Permanent Visa * Yes No
Current Location: At Home? * Yes No
If not at home, name of hospital, skilled nursing or assisted living facility:
Has the applicant had a previous nursing home stay in the past year? * Yes No
If Yes, dates of stay
Name of facility
Marital Status * Single Married Divorced Widowed Other
Race * White Black Latino Asian Other
Religion * Catholic Protestant Jewish Other church
Would you like to attend religious services at St. Ann's? * Yes No
Would you like a referral to Pastoral Care Services? * Yes No
Are you an organ donor? * Yes No
Are you or your spouse a US Veteran? * Yes No
Have you ever been a Resident of any St. Ann's Communities? * Chapel Oaks Cherry Ridge St Ann's Home The Heritage Adult Day Services No
* This completed application and PRI (Patient Review Instrument) must be submitted to St. Ann’s Home prior to consideration for admission. Submitting an application does not guarantee admission, nor does it mean that an applicant will be automatically placed on a waiting list. Placement is only offered after an application is fully reviewed by the Admissions Committee and is approved for admission.
Person to Notify in Case of Emergency
1st Contact * Power of Attorney Health Care Proxy
Name * First Last
Relationship *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone * - (###) - ### ####
Work Phone * - (###) - ### ####
Cell Phone * - (###) - ### ####
2nd Contact * Power of Attorney Health Care Proxy
Name * First Last
Relationship *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone * - (###) - ### ####
Work Phone * - (###) - ### ####
Cell Phone * - (###) - ### ####
3rd Contact * Power of Attorney Health Care Proxy
Name * First Last
Relationship *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone * - (###) - ### ####
Work Phone * - (###) - ### ####
Cell Phone * - (###) - ### ####
Medical History

(Please submit signed Release of Information in addition to application)
Primary Care Physician Name * First Last
Primary Care Physician Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Primary Care Physician Office Phone * - (###) - ### ####
Primary Care Physician Fax * - (###) - ### ####
Specialist Name * First Last
Specialist Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Specialist Office Phone * - (###) - ### ####
Specialist fax * - (###) - ### ####
(Please use separate sheet to list additional specialists if applicable)
Advance Directives

(Please provide copies of all advance directives)
Health Care Proxy * Yes No
DNR (Do Not Resuscitate) * Yes No
Living Will * Yes No
MOLST * Yes No
Insurance Information

(Please submit copies of all insurance cards with application)
Medicare # *
Medicare Type * Part A Part B
Medicare D Prescription Plan # *
MVP (under 65) #
MVP (over 65) #
Medicare Blue Choice # *
Traditional Blue Cross/Blue Shield # *
Blue Choice Senior # *
Other Insurance # *
Company *
Medicaid Information
Medicaid CIN # *
Case # *
County *
If Medicaid is not currently active,
has an application been completed? * Yes No
If Yes,
Date of Application
Caseworker Name *
Caseworker Phone * - (###) - ### ####
Do you have someone assisting you in
obtaining Medicaid? * Estate Planner/Financial Advisor Attorney 3rd Party Agency
Name * First Last
Phone * - (###) - ### ####
Has there been any transfer of assets (including but not limited to: money, stock, real estate) within the last 60 months? * Yes No
If yes, please provide details of transfer:
Long Term Care Insurance
Company *
Policy # *
Phone * - (###) - ### ####
Per Day Benefit: $ *
Is this a New York State Approved Policy? * Yes No
Living Situation Prior to Application
Lives Alone? * Yes No
Lives with Others? * Spouse Child Other No
Type of Dwelling * Home Apartment One Story Two Story Stairs?
If yes, how many stairs?
Frequent Falls? * Yes No
If yes, date of last fall? / MM / DD YYYY
Assistance Required? * Housekeeping Meal preparation Laundry Transportation None
Medical Equipment * Cane Walker Wheelchair Other None
Community Agency Care? * Yes No
If yes, name of agency
How Did You Hear About St. Ann's * Television Newspaper Internet Family member Physician Friend Church Mailing Other
Application Completed By:
Name * First Last
Relationship *
Date * / MM / DD YYYY
Financial Statement

Completion and submission of this data sheet is required prior to consideration for admission and an updated data sheet must be completed and submitted every six months after admission, or upon request.

**YOU MUST PROVIDE VERIFICATION OF ALL ASSETS & ACCOUNTS**
Monthly Income
Applicant Social Security ($) *
Applicant Private Pensionv *
Applicant Railroad Retirement ($) *
Applicant Veteran's Benefit ($) *
Applicant Annuities ($) *
Applicant Interest Dividends ($) *
Applicant Other Income ($) *
Applicant Total Monthly Income ($) *
Spouse Social Security ($) *
Spouse Private Pension ($) *
Spouse Railroad Retirement ($) *
Spouse Veteran's Benefit ($) *
Spouse Annuities ($) *
Spouse Interest Dividends ($) *
Spouse Other Income ($) *
Spouse Total Monthly Income ($) *
Assets

(Attach Additional Sheet, if necessary)
Savings
Bank Name *
Current Balance: $ *
Bank Name *
Current Balance: $ *
Checking
Bank Name *
Current Balance: $ *
Bank Name *
Current Balance: $ *
Certificates of Deposit
Bank Name *
Maturity Date *
Current Balance: $ *
Bank Name: *
Maturity Date *
Current Balance: $ *
Stocks/Bonds/Mutual Funds
Type of Investment: *
Where It's Held: *
Current Value: $ *
Type of Investment: *
Where It's Held: *
Current Value: $ *
Insurance Policies
Name of Company *
Current Value: $ *
Insurance term * Term Whole Life
Name of Company *
Current Value: $ *
Insurance term * Term Whole Life
Property
Primary Home Address: *
Current Value: $ *
Secondary Home Address: *
Current Value: $ *
Other Property: *
Current Value: $ *
Do You Have a Reverse Mortgage? * Yes No
Do you own both the property and the land? * Yes No
Do you have joint ownership of property? * Yes No
If yes, with whom?
STATE AND FEDERAL LAWS PROHIBIT DISCRIMINATION IN ADMISSION, RETENTION AND CARE OF RESIDENTS ON THE BASIS OF RACE, CREED, COLOR, BLINDNESS, MARITAL STATUS, PHYSICAL HANDICAP, NATIONAL ORIGIN, SEX, SEXUAL PREFERENCE OR SPONSOR.
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 also agree that the funds that are currently in the name of the applicant have been or will be used for the care of the applicant.
* I agree
Name * First Last
Date * / MM / DD YYYY
Relationship: *

St. Ann's Transitional Care Application

St. Ann's Transitional Care Application

Demographics

Person to Notify in Case of Emergency

Medical History (Please submit signed Release of Information in addition to application)

(Please use separate sheet to list additional specialists if applicable)

Advance Directives (Please provide copies of all advance directives)

Insurance Information (Please submit copies of all insurance cards with application)

Medicaid Information

Long Term Care Insurance

Living Situation Prior to Application

Application Completed By:

Financial Statement Completion and submission of this data sheet is required prior to consideration for admission and an updated data sheet must be completed and submitted every six months after admission, or upon request. **YOU MUST PROVIDE VERIFICATION OF ALL ASSETS & ACCOUNTS**

Monthly Income

Assets (Attach Additional Sheet, if necessary)

Savings

Checking

Certificates of Deposit

Stocks/Bonds/Mutual Funds

Insurance Policies

Property

STATE AND FEDERAL LAWS PROHIBIT DISCRIMINATION IN ADMISSION, RETENTION AND CARE OF RESIDENTS ON THE BASIS OF RACE, CREED, COLOR, BLINDNESS, MARITAL STATUS, PHYSICAL HANDICAP, NATIONAL ORIGIN, SEX, SEXUAL PREFERENCE OR SPONSOR.

Medical History

(Please submit signed Release of Information in addition to application)

Advance Directives

(Please provide copies of all advance directives)

Insurance Information

(Please submit copies of all insurance cards with application)

Financial Statement

Completion and submission of this data sheet is required prior to consideration for admission and an updated data sheet must be completed and submitted every six months after admission, or upon request.

YOU MUST PROVIDE VERIFICATION OF ALL ASSETS & ACCOUNTS

Assets

(Attach Additional Sheet, if necessary)