PERSONAL INFORMATION

Transcription

1 THE HOUSE OF THE GOOD SHEPHERD 798 Willow Grove Street Hackettstown NJ (908) APPLICATION FOR ADMISSION TO INDEPENDENT LIVING APARTMENT Applicant Name Home Address (Street Address and Apt#) PERSONAL INFORMATION Gender M F City State Zip Code Home Telephone # Address Date of Birth Age Ethnicity African American Caucasian Hispanic Asian Marital Status Single Married Widowed Divorced Separated Social Security Number Prior Occupation Name of Spouse (if applicable) Other Religion Name of Church/Synagogue (if affiliated) When are you planning to move in? Immediately (as soon as accommodations are available) Within 6 months How did you learn about The House of The Good Shepherd? Within 12 months Other Name on Medicare Card MEDICARE Medicare Number Part A Coverage (Date) Part B Coverage (Date) Is Your Medicare coverage provided through a Medicare Advantage Plan? YES NO If yes, Name of Plan OTHER INSURANCE (Medicare Supplement or Other Primary Insurance) Name of Insurance Policy (ID) Number Billing Address Policy Type Individual Group Group Name (if applicable) Group # (if applicable)

2 CONTACT INFORMATION Please list the names and addresses of family members or others who may be contacted with information and/or in case of emergency. Contact Name Mr. Mrs. Ms. CONTACT #1 Street Address and Apt# City State Zip Home Phone Cell Phone Work Phone Address Relationship to Applicant POA? Yes No Contact Name Mr. Mrs. Ms. CONTACT #2 Street Address and Apt# City State Zip Home Phone Cell Phone Work Phone Address Relationship to Applicant POA? Yes No

3 FINANCIAL INFORMATION (Confidential) TYPE OF INCOME Social Security SSI (Supplemental Security Income) Pension (Name of Company) Trust Other (Type) Other (Type) INCOME MONTHLY AMOUNT CASH AND BANK ACCOUNTS Type of Account Bank Name and Address Account # Account Balance LIFE INSURANCE Company Name and Address Type of Policy Face Value Cash Surrender Value

4 Description, Name and (if listed) Trading Symbol FINANCIAL INFORMATION (Confidential) STOCKS AND BONDS # of Shares Original Cost Current Value REAL ESTATE Type and Location Type of Interest You Hold Mortgage, if any Value OTHER ASSETS (Include vehicles and other items of value, e.g. coin collections) Type of Asset (Describe) Current Value DEBTS Creditor Name and Address Type of Debt Amount Owed

5 FINANCIAL INFORMATION (Confidential) MONTHLY EXPENSES Type of Expense Amount Type of Expense Amount Food (groceries, dining out) Utilities (cable, phone, cell phones, internet services) Transportation (car payment, insurance, gas, maintenance) Entertainment (vacations, memberships) Personal (clothing, hair care, housekeeping support) Gifts (family, charitable giving) Medigap Insurance Premiums Non-covered medical expenses (overthe-counter meds, supplies, deductibles) PRE-PAID FUNERAL ARRANGEMENTS Name of Funeral Home/Cemetery Value (if revocable) If applicant does not have pre-paid funeral arrangements, you must still provide the name and address of a funeral home for final arrangements: Name of Funeral Home: Location: Do you have long term care insurance? Yes No Please attach the following to your application: Copies of the front and back of your insurance cards Completed Prospective Resident Medical History Most recent 1040 filed Documentation of income and assets listed on application Copy of long term care insurance policy, if applicable Copy of Power of Attorney, if applicable Copy of Advance Directive, if applicable $100 non-refundable application fee

6 CERTIFICATION OF APPLICATION INFORMATION I hereby represent and certify that that information provided on this application is true and complete. I agree that I the event my funds are depleted and I can no longer afford the cost of my care, I will apply for any and all state or federal assistance that may be available. I further understand and agree that the policy of The House of the Good Shepherd is not to extend charitable care if a resident or patient transfers or dissipates assets other than to meet reasonable and customary living expenses. Applicant Date rev 06/13