Valley Eldercare Center Application


Valley Memorial Homes
Application for Admission

Personal Information

Applicant Name

First:
Last:
MI:
Nickname:

Address

Address:
City:
State:
Zip:

Phone Number

Home:
Work:
Cell:
Social Security:
Mother's Maiden Name:
Birthdate:
Education:
Birthplace:
Previous Occupation:
Gender:
Race:
Religion:
Home Church:

Marital Status

Current marital status:
Married    Never Married    Widowed    Separated    Divorced
If married, please list name of spouse:

Criminal Status

Have you ever been convicted of or plead guilty to a sexual offense in a court of law?
Yes    No
State:
County:

Veteran Status

Are you a Veteran?
Yes    No
Is your spouse a Veteran?
Yes    No
If yes, which branch?
If yes, which branch?
How did you hear about us?
Media    Word of Mouth    Healthcare provider    Other
Medical Information
Primary Physician:
Eye Doctor:
Dentist:
Funeral Home:
Address:
Phone:

Advanced Directives

Please check all that apply.
Copies REQUIRED upon admission.
Do you have a Durable Power of Attorney for Finances?
Yes    No
Name:
Email:
Do you have a Durable Power of Attorney for Healthcare?
Yes    No
Name:
Email:
Do you have a Guardian?
Yes    No
Name:
Email:
Do you have a Living Will?
Yes    No
Name:
Email:

Pharmacy

Pharmacies used by VMH tenants/residents must provide 24/7 service. Please choose one:


Skilled Nursing Residents Only:
Thrifty White Drug will be utilized when you are covered by Medicare A.
Do you currently use medications from the VA?
Yes    No
Emergency Notification
List in the order of whom you prefer we contact first
Primary Contact
 
 
Phone Numbers
Name:
Relationship:
Email:
Address:
Home:
Work:
Cell:
Secondary Contact - optional
 
 
Phone Numbers
Name:
Relationship:
Email:
Address:
Home:
Work:
Cell:
Tertiary Contact - optional
 
 
Phone Numbers
Name:
Relationship:
Email:
Address:
Home:
Work:
Cell:
Billing
Name:
Relation to Self:
Email:
Address:
Home:
Work:
Cell:
Insurance Information
Copies of cards REQUIRED prior to admission
Are YOU or YOUR SPOUSE currently employed part-time or full-time?
Yes    No
Are YOU or YOUR SPOUSE currently covered by an employer’s group health insurance?
Yes    No
If yes, name and policy number:

Medicare

Do you have Medicare?
Yes    No
If yes, Medicare Number:

Medical Assistance/Medicaid

Do you have Medical Assistance/Medicaid?
Yes    No
If yes, Medical Assistance/Medicaid Number:

Medicare Supplemental Insurance

Do you have Medicare Supplemental Insurance?
Yes    No
Company:
Policy #:
Phone #:
Have you ever applied for Medical Assistance/Medicaid?
Yes    No
If yes, date & county applied:

Medicare Replacement Policy

Do you have a Medicare Replacement Policy?
Yes    No
Company:
Policy #:
Phone #:

Other Health Insurance

Do you have Other Health Insurance?
Yes    No
Company:
Policy #:
Phone #:

Medicare D (prescription) Plan

Do you have a Medicare D (prescription) Plan?
Yes    No
Company:
Policy #:

Long Term Care Insurance

Do you have Long Term Care Insurance?
Yes    No
Company:
Policy #:
Phone #:
Financial Information
Information in this section will assist with financial planning.
Have you or your acting Financial Power of Attorney sold, traded, transferred, or gifted any cash or assets to you or from you, or to or from a trust account?
Yes    No   
If YES, please explain the nature of the transaction and the date it occurred.
Have you or your spouse resided on a farm in the past 5 years?
Yes    No   

Assets

Except for personal effects, list all the assets owned by YOU and YOUR SPOUSE, with the value as of the date of application.
Description of Assets
Approx. Value of Assets
Land
Checking
Savings - Passbook
Certificates of Deposit
Stocks, Bonds, IRAs, Annuities, etc.
Life Insurance - Cash Surrender Value
Home(s)
Vehicle(s)
Life Estate(s)
Trust   -   /
Trust - Year Created
Other

Debts

List all debts owed by you and your spouse, with outstanding balance as of the date of application. This includes mortgages, credit cards, vehicles or personal loansInclude any garnishments from Social Security or other income (tax lien, student loans, child support, etc.)
Description of Debt
Approx. Amount of Debt

Income

List all sources of income for YOU and YOUR SPOUSE, including but not limited to rental payments, CRP income, long term care insurance benefits, Social Security Benefits, Veteran Benefits, alimony, and employment income.
Description of Income
Frequency of Income
Amount of Income

SIGNATURE LINE The undersigned represent that all of the above statements are true and complete. The application complies with section 50-24.1-22 of the North Dakota Century Code, and I hereby authorize the long term care facility to contact any and all of the above identified financial institutions to obtain information regarding my assets and income, and I hereby release and authorize the financial institutions to release any information to the long term care facility. I further authorize the long term care facility to release to its attorneys any information regarding my application for admission.

Signature _______________________________
Date _______________________________