Worksheet Checklist -Nebraska Veterans' Home

Transcription

1 Wrksheet Checklist -Nebraska Veterans' Hme Cmplete the Wrksheet and btain all necessary dcuments BEfORE cntacting the Sarpy Cunty Veterans' Service Office at t schedule an appintment t cmplete the applicatin. If any questin des. nt apply, answer UNA r NONE". Veteran - Spuse, Surviving Spuse Gld Star Parent 1. Use numbers t indicate yur preference fr admissin t the Nebraska Veterans Hme (s) where yu want t reside 2. Prvide cmplete names, addresses, phne numbers, addresses, SSNs and dates in questins I t The Medical Reprt fr Admissin t Nebraska Veterans' Hme MUST be cmpleted and signed by Applicant's dctr. It MUST be cmpleted within 30 days prir t yur signing and ur submissin fyur Nebraska Veterans' Hme applicatin 4. Yu must prvide all financial infrmatin including incme, assets, investments and life insurance plicies 5. Prvide all dcuments as apprpriate fr yur applicatin, t include, but may nt be limited t: A cpy f Veteran's Military service all DD214(s) r statements f service All Marriage Certificate(s), All Divrce Decree(s) and spuse Death Certificate(s) [J Curt Orders, Prbatin Orders, Child Supprt, Garnishments Pwer f Attrney (POA), Durable Pwer f Attrney and/r Durable Pwer f Health Attrney and/r Durable Pwer f Attrney that includes health care decisins als Living Will and DNRIDRI Curt appinted Guardianship and/r Cnservatrship PrffNebraska residency - minimum 2 years Nursing Hme and/r Lng Term Care Insurance Plicies [J Medical Insurance Cverage cards, including Medicare and Medicaid & DVA Healthcare card Supplemental Medicare Insurance Plicy r card and dcumentatin fcsts Dcumented surces f All Incme. Retirement, V A Benefits, Scial Security and Investment Incme [J Dcumented surces f All Incme frm Business, Partnership, Farm andlr Rental Incme I.J Hme and Business/Rental Real Estate valuatin t include cunty assessr's real estate tax assessment Persnal prperty t include, but nt limited t, vehicles, farming and/r business equipment Current Bank Accunt statements fr checking and/r savings listing balances and jint wner's infrmatin CDs, lras, 401 Ks, Stcks. Bnds, Investment prtflis, end fyear statements and Trusts Life insurance plicies - cash/surrender value r face value/value upn death Land Cntracts r Sale f Prperty Cntracts, prperty transactin recrdings within the past 2 years Cmpleted and signed U.S. Citizenship Attestatin frm Ifyu have any questins regarding this wrksheet r required dcuments, please cntact us at Spuse is eligible fr admittance with the Veteran simultaneusly r after the Veteran has becme a resident f the Veteran's Hme System. Separate applicatins are required fr the Veteran and the Spuse. Mnthly maintenance fees assessed fr each member. Surviving Spuse is eligible fr admittance prviding they have nl remarried since the Veteran's dcath. Prvide a cpy f Veteran's Death Certificate and Affidavit f N Remarriage. Gld Star Parent is eligible fr admittance prviding Veteran's death was during active duty r service cnnected death. Prvide cpy f Veteran's Birth Certificate t establish parental relatinship.

2 Nebraska Department f Veterans' Affairs Veterans' Hmes Bard Guidelines Schedule f Allwances Effective 01/ The maintenance charge is determined n the husehld's ability t pay. The minimum maintenance charge is $0. $ 3, $ 7, $ 9, $19, $ 63, $ 8, SI6, $ $ $1, $ S N Cap N Cap N Cap N Cap N Cap Maximum maintenance charge. Maximum maintenance charge fr cuples. Assets allwed fr single members. Assets allwed fr married members. Assets allwed if spuse lives utside the V etcrans' hme. Irrevcable burial trust allwed fr single members. Irrevcable burial trust allwed fr cuples. Mnthly allwance fr single members. Mnthly allwance fr cuples. Mnthly allwance fr spuse living utside the Veterans' hme except n mnthly allwance is given fr a spuse in a private r public institutin when payment fr his/her care is frm the public agency. Mnthly allwance fr each dependent child except n mnthly allwance is given fr a dependent child in a private r public institutin when payment fr hislher care is frm a public agency. Maximum mnthly allwance fr prescriptins fr spuse living utside the Veterans' hme with prf f such expense. Maximum mnthly allwance fr health insurance premiums fr members andlr their spuses wh are nt eligible fr Medicare cverage with prf f such expense. Maximum mnthly allwance fr extended Medicare cverage fr member with prf f such expense. Maximum mnthly allwance fr extended Medicare cverage fr spuse living utside the Veterans' hme with prf f such expense. Maximum mnthly allwance fr Medicare Part D fr member with prf f such expense. Maximum mnthly allwance fr Medicare Part D fr spuse living utside the Veterans' hme with prf f sueh expense. :. Sale f hme is immediately cunted as an asset..:. Persnal hme is exempt as an asset fr 12 mnths after admissin. :. Hspital credit will be issued ifhspitalized ff campus fr 30 days r mre.

3 "" 'MEDICAL REPORT FOR 'ADMISSION TO NEBRASKAVETERANStHOME;~d?~r' j;:r'4~ L Patient Name Birth Date Gender [ 1 Male [ 1 Female I hereby, authrize the release f necessary medical infrmatin frm hspitals and ther medical prviders t the Nebraska Health and Human Services, The Nebraska Department f Veterans' Affairs, The apprpriate Cunty Veterans' Service Office and the Veterans' Hme Bard in rder t establish eligibility fr admissin the NebraSka Veterans' Hme System. Date: Patient r Authrized Signature: ALL SECTIONS MUST BE COMPLETED. IF IT DOES NOT APPL Y MARK WITH N/A OR NONE. Diagnsis (include alchlism, drug abuse and psychpathlgy) Check any f the fllwing if they are present: Test Date Results Disabilities Impairments Mild Md. Sev. Activity Tal. Limits Chest x-ray Amputatin Speech Nne C.B.C. ParalysiS Hearing 0 Mderate Serlgy Cntracture Visin 0 Severe Urinalysis Decub. Ulcer Sensatin Other Tremrs t= Infectins - please specify (MRSA, VRE, IV antibitics, etc.) Nne OTetanus Sht LYes L N Date: Influenza Sht I Yes I N Date: Pneumcccal Plysacharide Vaccine IYes IN Date: Behaviral issues - please specify (wandering, anger, etc.) Wandering Anger utbursts Delusinal Behavirs Resists cares Sexual Inapprpriateness Nne Cmpulsive Behavirs Specify: Present Medicatins: (may attach printut) Allergies - please specify ONKA Diet: Regular Mdified (specify e.g., salt free, 1800 calrie limit, etc.) Patient Acceptance f illness I disability Understands reasn fr placement PartiCipated in Plan D Gd DYes DYes [J Fair Partly N Pr DNa N/A Family Participated in Planning Accepted Nursing Hme Plan Expected t Visit DYes DYes DYes DNa OReluctantly DNa N/A ON N/A

4 Patient Name: Scial # Self-Care Status Inde Needs Assistance Unable t D Has Uses Needs Persnal H iene Occasinally Disriented I Cnfused fr 1-'<::'"r.n,l)ur"lr. Treatment Is Patient Capable f Making Health Care Decisins? ~=a~====~======================9."'".n".c:is 0 Yes N DYes 0 N (Include bservatins, instructins given t patient I family regarding illness, treatment, etc.) Prgnsis: Feeding Tube Oxygen Specify: Anticipated Rehabilitatin needs: Nne Anticip care: Revised 11/25114

5 Sarpy Cunty Wrksheet VETERANS HOME SYSTEM Applicatin fr Admissin 1. Shw rder f preference ONLY fr the Hme(s) in which yu wuld want t reside (e.g. 1", 2"', etc.l: Grand Island Nrflk Bellevue Scttsbluff 2. Veteran: Last Name First Name Middle Name Sc. Sec. N, Date f Birth 3. Applicant: Male Last Name First Name Middle Name Sc. Sec. N, 'Date f Birth 0 Female a. Relatinship if nt veteran: Spuse Widw Widwer Gld Star Father Gld Star Mther 4, Address f Applicant: Street Address City State lip Cde Cell 0 Hme Phne N. Daytime Phne N, a. Present lcatin f applicant: D Hspital Nursing Hme Name f Hspital Name f Nursing Hme DAtHme Other: b. Present address: (if ther than wn hme) Street City State lip Cde Cell 0 Hme Phne N. 5. Veteran's Military Infrmatin: ATTACH COPY OF DISCHARGE DOCUMENT 6. Attestatin Frm: ATTACH COPY OF ATTESTATION FORM 7. Medical Reprt: Date Cmpleted ATTACH COPY OF MEDICAL REPORT 8. Marital Status: Single 0 Married 0 Widwed Divrced 0 Separated ATTACH APPROPRIATE DOCUMENTS 9. Spuse: Name Sc, Sec. N. Date f Birth Address: Street City State Zip Cde 10. Cntact Persn lther than spuse): Cell 0 Hme Phne N. Daytime Phne N. 1, Name Relatinship Address City State Zip Cell 0 Hme Phne N. Daytime Phne Number 11. Name f Legal Dependents (ther than spuse): 1. Name Relatinship Date f Birth Adress Hme Phne N. Daytime Phne Number Page 1 f4

6 Sarpy Cunty Wrksheet 12. Has applicant executed (a) pwer f attrney? 0 Yes 0 N (b) pwer f health attrney? 0 Yes 0 N (c) pwer f attrney that includes health care decisins? OYes ON ATIACH COpy OF LEGAL INSTRUMENT (d) Living Will? OYes D N ATIACH COpy OF LEGAL INSTRUMENT 13. Des applicant have a curt-appinted guardian/cnservatr? 0 Yes 0 N a. If yes, name, address and phne number f guardian/cnservatr ATIACH COpy OF LEGAL INSTRUMENT Name Relatinship Street Address City State Zip Cde Cell 0 Hme Phne N. Daytime Phne Number 14. Has the Veteran lived in Nebraska fr tw years at any time? Yes 0 N 15. Have yu, the applicant, lived in Nebraska fr tw years at any time? Yes 0 N 16. Have yu ever made applicatin and/r been a member f a Nebraska Veterans Hme? Yes 0 N If yes, date f applicatin and/r admissin Date f Discharge 17. Have yu ever been cnvicted f a felny? 0 Yes 0 N If s, state ffense 18. Des applicant have nursing hme insurance? 0 Yes 0 N 19. Are yu currently enrlled in the USVA Health Care System? 0 Yes ON 20. Supplemental insurance t Medicare? OYes ON Premium Annual r 0 Mnthly 21. If married, des spuse have supplemental insurance? 0 Yes 0 N Premium Annual r 0 Mnthly 22. Des applicant have primary health insurance ther than Medicare? 0 Yes 0 N Premium Annual r 0 Mnthly 23. Des spuse have primary health insurance ther than Medicare? [] Yes 0 N Premium Annual r 0 Mnthly 24. VA Service Cnnected Cmpensatin: Percent FINANCIAL STATEMENT OF ApPLICANT 25. VA Nn-Service Cnnected Pensin: Aid & Attendance: 0 Yes 0 N Husebund: DYes D N 26. Dependency and Indemnity Cmpensatin (Ole) 27. Death Pensin (Dependent) 28. Scial Security: a. Medicare Cverage 0 Yes 0 N Medicare #: Mnthly Premium: Net 29. Other incme (list surces and amunts): MONTHLY AMOUNT: 30. ApPLICANTS TOTAL INCOME Incme f spuse if nt shwn abve as the applicant fr admissin: (list surce and amunts) 32. Incme f dependents: (list surce and amunts) 33. TOTAL INCOME OF SPOUSE AND DEPENDENTS Page 2 f 4

7 Sarpy Cunty Wrksheet ASSETS Cmplete entries belw shwing all assets f the applicant & spuse. Shw assets held individually and jintly. 34. D yu wn real estate? (Cmplete entries belw) 0 Yes 0 N a. Persnal Residence... Assessed Value Address Des yur spuse r ther dependents live in this residence? 0 Yes 0 N b. Rental Prperty (Le. rental residence, farms, ranch)... Assessed Market Value Explain c. Other persnal prperty (includes, but nt limited t land hldings, vehicles, livestck, farming/business equipment). List items with market value fr each Ttal Market Value f item "c" 35. TOTAL WORTH OF REAL ESTATE & PERSONAL PROPERTY (lines 34a thrugh 34c) Bank checking and savings accunts: a. Amunt in bank checking accunt Name and address f bank(s) 2. Is this a jint accunt? 0 Yes 0 N If yes, give name and address f ther persn(s) b. Amunt in savings accunt Name and address f bank(s) 2. Is this a jint accunt? 0 Yes 0 N 37. Other investments & Life Insurance Plicies - cash/surrender value and face value/value upn expiratin: (I ist surces a nd amunts) a. Are any f the investments held jintly? 0 Yes 0 N If yes, identify each security in additin t the name fthepersn 38. Have yu transferred r assigned wnership f real r persnal prperty t any persn r entity up t tw years prir t this applicatin? 0 Yes 0 N IF YES, PLEASE PROVIDE COpy OF APPROPRIATE DOCUMENTS. 39. Have yu sld real estate r persnal prperty fr which yu hld the mrtgage, ntes r land cntract? 0 Yes 0 N 40. TOTAL OF AsSETS (lines 36a thrugh 37a)..... Page 3 f 4

8 WHEN COMPLETED, PLEASE CONTACT THE VETERANS SERVICE OFFICE TO SCHEDULE AN APPOINTMENT AT