Bom Admission Questionnaire

SKILLED NURSING ADMISSION QUESTIONNAIRE

PLEASE COMPLETE ALL SECTIONS

Date*

I. APPLICANT DEMOGRAPHICS:

A. Name of Applicant*

First Last

B. Address*

Street Address Address Line 2 City State ZIP Code

C. Home Phone*

Cell Phone

Work Phone

Email Address

Religion

D. Social Security Number

Gender*

Male
Female

E. Date of Birth*

Place of Birth

F. U. S. Citizen*

Yes
No

If yes, is proof available?*

Yes
No

G. Marital Status*

Married
Never Married
Widowed
Separated
Divorced

Name and Address of Spouse*

H. Employment Status

Full Time
Part Time
Retired
Not Employed

I. Employed Where*

Lifetime Occupation:

J. Location of Applicant*

K. Previous Nursing Home Stays

Yes
No

Name of Facility*

Start Date*

End Date*

L. Primary Doctor*

Prefix First Last

II. RESPONSIBLE PARTY/EMERGENCY CONTACT

The Brothers of Mercy requests that to the greatest extent feasible, the individual named as the Financial/Designated Representative for the applicant to be an existing attorney-in-fact for the applicant, or be granted a Durable Power of Attorney by the applicant as soon as possible to ensure continuity of payment of all expenses incurred to the extent of the applicant's resources.

Name*

Financial/Designated Representative (manages finances for the applicant).

First Last

Relation*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone

Work Phone

Email Address

Bank POA:

Yes
No

Upload Proof of Bank POA:*

Max. file size: 8 MB.

Durable POA:

Yes
No

Upload Proof of Durable POA:*

Max. file size: 8 MB.

Health Care Proxy

Yes
No

Upload File: Proof of Health Care Proxy*

Max. file size: 8 MB.

Conservator/Guardian:

Yes
No

Upload Files Proof of Conservator/Guardian:*

Max. file size: 8 MB.

B. Primary Emergency Contact

Name*

First Last

Relation*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Work Phone

Email Address

Health Care Proxy

Yes
No

III. INSURANCE COVERAGE

A. Veteran*

Yes
No

Spouse Veteran*

Yes
No

B. Medicare Number*

C. Medicaid CIN Number

Medicaid Effective Date

If Medicaid Pending, Interview Date

D. Long Term Care Insurance*

Yes
No

Provider*

E. Other Medical Insurance (BC/BS, IHA, Univera, EPIC, No Fault)*

Yes
No

Provide Copies of all Insurance, Medicare, Pharmacy & Social Security Cards

Company / Insurer	ID #	Monthly Premium

Provide copies of all Insurance, Medicare, Pharmacy & Social Security cards*

Max. file size: 8 MB.

F. Medicare Part D Plan & ID

IV. STATEMENT OF INCOME

A. Social Security*

Applicant $	Spouse $

SSI

Applicant $	Spouse $

Retirement/Pension

Applicant $	Spouse $

Veteran's Pension

Applicant $	Spouse $

Rental Income

Applicant $	Spouse $

Other Income

Applicant $	Spouse $

Describe the Source of Other Income*

Consent to change of address for Monthly Income

Yes
No

(This only needs to be answered for Long Term Care)

V. ASSETS/RESOURCES:

A. Real Estate*

Yes
No

Real Estate*

Location	Value $

B. Life Insurance*

Yes
No

Life Insurance*

Face Value $	Cash Value $

C. Prepaid Funeral*

Yes
No

Funeral Location*

D. Trust*

Yes
No

Trust Name*

Name	Date Established

E. Additional Assets / Resources - Applicant or Joint with Applicant

Account Name	Type of Account	Balance

Checking, Savings, CD's, Stocks, Bonds, 401K, Trusts, Annuities, Money Market, etc.

Are any of the above annuitized?*

Yes
No

Total Balance*

VI. LIABILITIES:

A. Home Mortgage:*

Yes
No

Home Mortgage Amount Owed*

B. Loans:*

Yes
No

Loans Amount Owed*

C. Credit Cards*

Yes
No

Credit Cards Amount Owed*

D. Other Debts (home equity, etc.):*

Yes
No

Other Debts Amount Owed*

VII. DIVESTING

A. Has applicant/financial representative transferred assets or property in the past 60 months to a life estate or to someone other than yourself?*

Yes
No

Transferred Assets in past 60 Days*

Value $	Date of Transfer

B. Has applicant given gifts of money in the last 60 months?*

Yes
No

Given Gifts in last 60 months*

Value $	Date of Gift

C. Has applicant issued any Promissory Notes?*

Yes
No

Promissory Notes?*

Value $	Date of Issue

D. Applicant been part of a Personal Care Agreement?*

Yes
No

Personal Care Agreement*

Describe	Date of Agreement

E. Additional Financial Information

F. Has applicant contracted with a placement agency?*

Yes
No

Personal Care Agreement*

Name of Agency	Agency Contact

(*Please note that Brothers of Mercy is not contracted with any third party referral agencies. Under no circumstances will any Brothers of Mercy facility pay a referral fee for placement of any resident at any Brothers of Mercy facility.)

VIII. COUNSEL

Are you currently working with an attorney or other firm for Estate or Medicaid Planning?*

Yes
No

List the Name of Estate Planning & Medicaid Planning Firm*

Estate or Medicaid Planning Firm

Counsel Statement and Agreement

Name*

First Last

the resident and/or the Designated Representative, each separately and individually. warrant the financial information submitted to the facility concerning the Resident's finances are true, accurate and complete in all material respects. and that there are no material omissions. I/we acknowledge that the Brothers of Mercy has relied and will continue to rely upon my/our truthful representation of all of the Resident's known income, assets, resources and liabilities, as well as my/our full disclosure of any transfers of income, and that my/our misrepresentation of failure to provide full disclosure my result in an interruption in payment or in qualification for benefits for payment of expenses incurred by the resident. The Resident and/or Designated Representative assure payment of all expenses incurred to the extent of the applicant's resources.

REPRESENTATIONS, WARRENTIES AND INDEMNIFICATION AGREEMENT 1. Upon satisfactory review of the Questionnaire, including the representations and warranties made herein, The Brothers of Mercy will consider the Resident for admission. 2. The Resident and Representative each acknowledge the Brothers of Mercy’s reliance on the statements Made by them in the Admission Questionnaire and the promises made herein and agree to indemnify and hold The Brothers of Mercy harmless from any, and all liability, loss, expense, and/or damage which The Brothers of Mercy may incur by reason of any misrepresentation contained in either document or their noncompliance with either document. 3. The Resident and Representative represent and warrant to The Brothers of Mercy that the Resident’s assets are fully and accurately disclosed on the questionnaire and that there have been no transfers of the Resident’s ownership interest in any assets or resources within the past 60 months for which fair payment has not been received other than those listed in section VII. 4. The Resident and Representative agree that neither of them has previously done anything nor will either of them at any time hereafter do anything that would cause the Resident to become ineligible or disqualified for Medicaid for any period of time whether by reason of having transferred the Resident’s present or future acquired assets without receiving fair payment or value in exchange for such transfer or otherwise. 5. If the Resident is the owner of a residence, the Resident and Representative represent and warrant that if And when the Resident no longer intends to return to such residence, such residence will be promptly sold for Fair value and the proceeds used to discharge Resident’s obligations to The Brothers of Mercy if, and when other resources are exhausted. Prior to exhausting Resident’s other assets, they will list the residence for sale (with an M-L broker) for its then fair market value and diligently pursue the closing of a sale of the residence. The proceeds of the sale will be held and used solely for discharging Resident’s legal obligations, including the Obligations to The Brothers of Mercy. 6. The Resident and Representative agree that prior to exhausting the Resident’s assets and resources, they will Make timely application for Medicaid. The application shall be made in such manner and at such time that the Resident will be able to pay his/her obligations to The Brothers of Mercy by means of the Resident’s assets and Resources and/or medical assistance provided by the State of New York or other government agency. 7. If the resident is denied timely Medicaid coverage due to the willful or negligent failure of Resident and/or Representative to abide by this agreement, they agree to indemnify and hold The Brothers of Mercy harmless Of and from any, and all loss or damage accessioned by any misrepresentation or failure to qualify for Medicaid and they each agree to pay and reimburse The Brothers of Mercy unconditionally all amounts that The Brothers of Mercy would have received had a timely Medicaid pick-up date occurred. 8. The liability of the Resident and the Representative for all damages incurred by The Brothers of Mercy as a Result of the breach by either of them of any of the covenants and representations made herein will be joint and several. Nothing herein, however, shall be constructed to be a personal guaranty by the Representative of the obligations of the Resident to The Brothers of Mercy for the room, board and/or care provided to Resident at The Brothers of Mercy except to the extent that such obligation arises as a result, of a breach of the Covenants made herein. I have reviewed the information contained herein, and represent that it is a factually true, accurate and complete. I understand that The Brothers of Mercy utilizes this information in the admissions decision process. The above terms and conditions will become effective and be binding upon and enforceable against the Resident and the Representative upon admission of the Resident pursuant to this Questionnaire.

The BROTHERS OF MERCY DOES NOT DISCRIMINATE IN THE ADMISSION, RETENTION AND CARE OF RESIDENTS BECAUSE OF AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, HANDICAP, SEX, AGE, SOURCE OF PAYMENT, MARITAL STATUS, AND SEXUAL PREFERENCE.

I ATTEST*

Yes
No

I hereby declare that all statements made herein are true according to the best of my knowledge and belief. In witness whereof. I have hereunto set my hand to this application.

Authorization for Use or Disclosure of Protected Health Information

Applicants Name

First Last

I hereby authorize the use and disclosure of my health information as indicated below. I understand that this release is voluntary and that I may revoke this authorization at any time except to the extent that action has been in reliance on this authorization. I also understand that if the individual or organization authorized to receive this information is not required to comply with current privacy regulations, my health information may be disclosed to others and no longer protected by current state and federal privacy regulations.

I hereby authorize my Primary Care Physician and/or any other Physician involved in my care to release the information listed below upon submission of my application to the Brothers of Mercy Campus for the purpose of determining medical needs:

History & Physical Examination
Laboratory Reports
Transcribed Reports
Medical / Treatment Records
Consultant Reports
Other

Unless otherwise revoked by me, I understand that this authorization will expire 90 days from the date on the Admission Questionnaire or upon the completion of the use of the information for the purpose it was intended, whichever is earlier.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits.

I understand that I may inspect and copy any information used or disclosed under this authorization. I understand that a fee may be charged for such copying services.

I hereby release the facility, its employees, officers, and health care professionals from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

I understand that I may revoke this request at anytime by providing the facility with my written notice of such revocation.

Date

Signature of Resident

Name of Resident

First Last

Date

Signature of Representative

Name of Representative

First Last

Relationship to Resident

Date

Signature of Witness

Name of Witness

First Last