Application for Hurlbut Care Communities

Application For Hurlbut™ Care Communities

Date: ______

This form serves as a preliminary application for all Hurlbut Care Communities. You may be contacted for additional information. Please place a check mark beside the facility or facilities you want to receive this application.

❒ Avon Nursing Facility ❒ Newark Manor ❒ The Brightonian ❒ Penfield Place

❒ Conesus Lake Nursing Facility ❒ Seneca Nursing and Rehabilitation Center ❒ Elm Manor ❒ The Shore Winds

❒ Hornell Gardens ❒ Wedgewood Nursing Facility ❒ The Hurlbut ❒ Woodside Manor

❒ The Fountains (Boca Raton, Florida) Name of Applicant:

Last First MI

Home Address: ______

County Of Residence: Birthdate: ______Sex: ❍ M ❍ F

Home Phone: ______Work Phone: ______Cell Phone: ______

Marital Status: ❍ Single ❍ Married ❍ Widowed ❍ Divorced

Name of Spouse: ______Date of Marriage: ______If deceased, when? ______

Spouse Employed: ❍ Yes ❍ No Spouse’s Employer: ______

Religion: ______Name of Church or Synagogue: ______

U.S. Citizen:: ❍ Yes ❍ No If naturalized U.S. citizen, date of naturalization:______

Are either you or your spouse a United States Veteran? ❍ Yes ❍No

Current Location of Applicant: ______

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

Name of Hospital:______Date of Stay: ______

Reason for Hospitalization: ______

Has the applicant had a previous nursing facility stay? ❍ Yes ❍ No

If yes, please list the names of the facility and the dates of their stay: ______

Permanent Visa: ❍ Yes ❍ No Year Visa Obtained: ______

Primary Language: ______Secondary Language: ______

Applicant Employed: ❍ Yes ❍ No Applicant’s Employer: ______

Lifetime Occupation: ______Social Security Number: ______

RESPONSIBLE PERSONS

FINANCIAL REPRESENTATIVE: Oversees financial obligations of Applicant.

Name of Representative: ______

Last First MI

Address: ______City: ______

County:______State: ______Zip code: ______

Relationship to Applicant: ______Home Phone: ______

Work Phone: ______Other Phone: ______

Bank Power of Attorney: ❍ Yes ❍ No Durable Power of Attorney: ❍ Yes ❍ No Committee of Estate: ❍ Yes ❍ No Conservatorship/Guardian: ❍ Yes ❍ No

Any Pending Status(es): ❍ Yes ❍ No If yes, please explain: ______

Has there been any transfer of funds or assets, including but not limited to real estate in the past 60 months?

❍ Yes ❍ No If yes, please explain:______

DESIGNATED REPRESENTATIVE: Oversees needs of Applicant.

❍ Check here if same as above, otherwise please provide information below:

Name of Representative: ______

Last First MI

Address: ______City: ______

County:______State: ______Zip code: ______

Relationship to Applicant: ______Home Phone: ______

Work Phone: ______Other Phone: ______

Health Care Proxy established: ❍ Yes ❍ No If yes, name/address of proxy: ______

Have Advanced Directives been established (Living Will, DNR): ❍ Yes ❍ No

If yes, copies will be made requested upon admission.

Funeral Home Name/Address/Telephone:______

Anatomical Gift Program: ❍ Yes ❍ No If yes, please explain: ______

______

INSURANCE COVERAGE

Medicare #: ______Hospital Coverage Part A? ❍ Yes ❍ No Effective date: ______

Medical Coverage Part B? ❍ Yes ❍ No Effective date: ______

Medicare D: ______

Medicaid Case #: ______Medicaid County: ______

Effective Date: ______Case Worker’s Name: ______

Case Worker’s Telephone: ______

Long Term Care Insurance: ❍ Yes ❍ No If yes, Company Name/Address/Telephone: ______

Other Medical Insurance: ❍ Yes ❍ No If yes, Company (Certificate #/Prescription Card Number): ______

Please note! Copies of all insurance cards will need to be provided at the time of admission.

FINANCIAL INFORMATION

Monthly

Income Expenses

Social Security:______Health Insurance Premium: ______

Pension: ______Mortgage: ______

V.A. Benefits: ______Rent: ______

Annuities: ______Utilities:______

Railroad Retirement: ______EPIC: ______

SSI: ______Other: ______

Other: ______Other: ______

Bank Accounts

Bank:______Account #: ______

Type of Account: ______Current Balance:______

Bank:______Account #: ______

Type of Account: ______Current Balance:______

Assets

C.D.s: ______

Trust: ______

Real Estate: ______

Stocks/Bonds: ______

Life Insurance: ______

Liabilities

Debts: ______

Other: ______

To the best of my knowledge, all the information provided is accurate and true:

Name: ______

Signature: ______

State and Federal Laws Prohibit Discrimination in Admission, Retention and Care of Residents on the Basis of Race,

Color, Age, National Origin, Blindness, Marital Status, Physical Handicap, Sex, Sexual Preference or Sponsor.