SKILLED NURSING ADMISSION QUESTIONNAIREPLEASE COMPLETE ALL SECTIONSDate* MM slash DD slash YYYY I. APPLICANT DEMOGRAPHICS:A. Name of Applicant* First Last B. Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code C. Home Phone*Cell Phone*Work PhoneEmail Address* Religion* D. Social Security Number*Gender* Male Female E. Date of Birth* MM slash DD slash YYYY 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* MM slash DD slash YYYY End Date* MM slash DD slash YYYY L. Primary Doctor* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last II. RESPONSIBLE PARTY/EMERGENCY CONTACTThe 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 PhoneEmail 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 ContactName* First Last Relation* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Work PhoneEmail Address* Health Care Proxy* Yes No III. INSURANCE COVERAGEA. Veteran* Yes No Spouse Veteran* Yes No B. Medicare Number*C. Medicaid CIN Number*Medicaid Effective Date* MM slash DD slash YYYY If Medicaid Pending, Interview Date* MM slash DD slash YYYY 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 / InsurerID #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 INCOMEA. 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*LocationValue $ B. Life Insurance* Yes No Life Insurance*Face Value $Cash Value $ C. Prepaid Funeral* Yes No Funeral Location*D. Trust* Yes No Trust Name*NameDate Established E. Additional Assets / Resources - Applicant or Joint with Applicant*Account NameType of AccountBalance 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. DIVESTINGA. 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*DescribeDate of Agreement E. Additional Financial Information*F. Has applicant contracted with a placement agency?* Yes No Personal Care Agreement*Name of AgencyAgency 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. COUNSELAre you currently working with an attorney or other firm for:* Yes Estate Planning List the Name of Estate Planning & Medicaid Planning*Estate Planning Firm Are you currently working with an attorney or other firm for:* Yes Medicaid Planning List the Name of Medicaid Planning Firm*Medicaid Planning Firm Counsel Statement and AgreementName* 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, GENDER, MARITAL STATUS, SEXUAL PREFERENCE, BLINDNESS, DISABILITY OR HANDICAP.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.
