Admissions Application

ADMISSIONS APPLICATION

Thank you for your interest in Fairport Baptist Homes.Please take a moment to fill out this form as thoroughly as possible. We want to process your application in a timely fashion and incomplete applications or excluding copies of the following may result in a delay:

Social Security CardBody Organ Donor Card

Medicare CardLong-term Care Insurance Card

Medicaid CarePower of Attorney

Major Medical Insurance CardHealth Care Proxy

Prescription Plan CardLiving Will

Rehabilitation applicantsare encouraged to call your insurance carrier to obtain details regarding your coverage for short-term skilled nursing rehabilitation. It is also important to note that even if you have the rehabilitation benefit, you still must meet criteria/qualifications set forth by your insurance carrier in order to qualify for admission. You should be aware, in advance of potential placement, of any co-payments and/or deductibles you may have upon admission to our rehabilitation facility.

Name: ______

Prescheduled surgery date: ______

Procedure: ______

Hospital: ______

Long-term care applicantsare required to have appointed, prior to admission, a Power of Attorney and Health Care Proxy. In addition to this application, the Fairport Baptist Homes Financial Disclosure form is also required for all long-term care applicants.

This application and any related documents can be mailed to Fairport Baptist Homes at:

4646 Nine Mile Point Road, Fairport, NY, 14450. You can also return via e-mail to , or via fax at (585) 388 2388.

Application is being submitted for (please circle): Short-term rehabilitation or Long-term Care

Name: ______

Address: ______Phone: ______

County of Residence: ______Email:______

Marital Status (please circle): Married Widow/Widower Single Divorced

Demographic Information:

Date of Birth: ______Birth place: ______

Social security number:______

US Citizen (please circle): Yes No If naturalized, date: ______

Veteran (please circle): Yes No

Occupation: ______

Most recent employer:______

Highest level of education: ______

Church membership/denomination: ______

Insurance Information:

Medicare number: ______

Medicaid number: ______County: ______

Major Health Insurance provider (i.e. Excellus or MVP):______

Contract number______

Medicare part D (prescription plan):______

Do you have long-term care insurance (please circle): Yes No

If yes, company name: ______

Contract number: ______

Please list any other third party insurance (i.e. MVA or WCP):______

Claim Number:______

Claims adjustor:______

Contact information:______

Primary Contacts-please list in order to be contacted:

Name: ______Relationship: ______

Address:______

Home Phone:______Cell Phone:______

Work Phone:______Email:______

Name: ______Relationship: ______

Address:______

Home Phone:______Cell Phone:______

Work Phone:______Email:______

Name: ______Relationship: ______

Address:______

Home Phone:______Cell Phone:______

Work Phone:______Email: ______

Financial representative (Power of Attorney and/or Guarantor) and information:

Name:______

Relationship to applicant:______

Address:______

Home Phone:______Cell phone:______

Work Phone:______Email:______

Please refer to financial disclosure form for other necessary financial information required (long-term care applicants only)

Please list any recent hospital stays and/or nursing home stays within the past thirty days:

Hospital:______

Dates of Stay:______

Nursing home:______

Dates of Stay:______

Primary Care Physicians Name:______

Address:______

Phone:______Fax:______

Please list any other Physician/Specialists whom the applicant sees on a regular basis:

Name:______

Address:______Phone:______

Specialty:______

Name:______

Address:______Phone:______

Specialty:______

Name:______

Address:______Phone:______

Specialty:______

Funeral Home/Burial Instructions (long-term care applicants only):

Funeral Home Name:______

Address:______

Phone number:______

Cemetery:______

Organ donator (please circle): Yes No

CONSENT TO RELEASE INFORMATION TO FAIRPORT BAPTIST HOMES

I,______, an applicant for admission to Fairport Baptist Homes, do hereby agree that any false answer to the statements herein submitted shall be cause for rejection of this application.

Fairport Baptist Homes, or its accredited representatives, has my permission to obtain full and detailed information from any doctor, hospital, or clinic to whom I am or have been known to regarding any consultations I have had with them, including the reason, the diagnoses, and the nature and result of treatment. I also authorize any holder of medical or other information about me to be released to the Social Security Administration, or its intermediaries or carriers, any information needed for any Medicare or insurance claim. I request that payment of authorized benefits be made on my behalf.

I hereby certify that the answers to the above mentioned questions are full and complete and I have truthfully answered all questions.

Signed:______Date:______

(May be signed by applicant or legal representative)

Relationship to applicant:______

Name______Completion Date______

MONTHLY INCOME

Source of Monthly Income / Applicant / Spouse
Please provide monthly dollar amount for income
Social Security
Private Pension: Source:
Retirement, SSI, Veterans
Other: Please List:
Other: Please List:
Other: Please List:

TRUST: Please indicate if a Trust has been established YES NO Date of Trust______

Irrevocable Revocable or other______

BURIAL FUND: Has a burial Fund/Trust already been established? YES NO

Accounts / Location / Amount / TRUST
Checking
Checking
Savings
Savings
Stocks/Bonds/CD’s
Stocks/Bonds/CD’s
Stocks/Bonds/CD’s
IRA’s/401/403B
Life Insurance – Cash Value
Other:

LIQUID ASSETS (Liquid Assets are monies which can be liquidated and utilized for Applicants care)

If a Trust has been established please check which assets are included in the Trust in the right column

REAL ESTATE

Property Location / Owners listed on deed / Value / TRUST

LONG-TERM CARE POLICY

Company Name / Policy Number / SNF Benefit details

LIABILITIES – Please list outstanding debts (e.g. mortgage, loans, credit card, real estate)

Liability / Amount Owed

ASSET TRANSFER

Current look back period when applying for Medicaid is five (5) years. It is important to know that transfers of assets within this look back period could potentially result in a penalty or denial of Medicaid eligibility by the Department of Social Services. Assets can not only be monetary but real estate, land, stocks and investments.

ASSET TRANSFERRED / TRANSFERRED TO / AMOUNT OF TRANSFER

Has a Medicaid application been submitted on behalf of the applicant? YES NO

Date of application submission:______County______

Name of Case Worker______Phone______

I hereby declare that the statement of assets and monthly income levels are true to the best of my knowledge and belief. Upon completion of this form, I acknowledge that the total of the applicants resources is $______and these assets/monies will be utilized for the services and care provided by the Fairport Baptist Homes.

It is mandated that the Fairport Baptist Homes be notified three (3) months prior to the exhaustion of resources available for the applicants care so that the Medicaid application can be initiated. The Fairport Baptist Homes reserves the right to request additional financial information including, but not limited to, copies of financial statements and/or the most recently completed 1089 form(s).

Please be advised that upon admission to the Fairport Baptist Homes skilled nursing that a security deposit equal to one months’ (30 days) private room rate is required for all private pay Residents.

Print Name______

Signature Power of Attorney/Responsible

Party______Date______

Pease note, Fairport Baptist Homes is a completely smoke-free facility. Admission to Fairport Baptist Homes is made regardless of age, race, creed, color, national origin, sex, disability, sexual orientation, marital status, or source of payment.