This Application is for: *

Immediate Need
Future Need
Months/Years

Applying For: *

How did you hear about St. Anne's Retirement Community?

Name *

First

Last

Social Security #

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email

Cell Phone

Home Phone *

Date of Birth *

Place of Birth

Gender *

Male
Female

Marital Status *

Married
Single
Widow

Spouse's Name

Do you have an Advanced Directive/Living Will? *

Yes
No

Do you have a Durable Power of Attorney (POA) for Health Care? *

Yes
No

Power of Attorney's Name

Phone

POA's Address

Address Line 1

Address Line 2

City

State

Zip Code

POA's Email *

Type of POA

Financial
Medical
Financial & Medical

Do you have a Will? *

Yes
No

If yes, who is the Executor?

Family

Children/Significant Other (Please list individuals in the order they should be contacted if unable to reach POA)

Name *

First

Last

Relationship *

Work Phone

Cell Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email

#2

Name

First

Last

Relationship

Work Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

#3

Name

First

Last

Relationship

Work Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Care Preference

To Be Admitted From

If Hospital- Name and Unit

List inpatient Stay Dates for Past Year (Hospital, Other Facility, Transitional Care, etc.)

Long Term Care Goal *

Primary Health Insurance (Medicare, Advantage Plan, PPO)

Insurance Company *

Policy / ID Number *

Group Number (if applicable) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

If Health Insurance is Medicare: Part A Effective Date

If Health Insurance is Medicare: Part B Effective Date

Secondary Health Insurance

Carrier Name

Insured Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Policy/ID #

Group Number (if applicable)

Annual cost for insurance is

Do you have Long Term Insurance? *

Yes
No

Policy # *

Daily Personal Care Benefit *

Daily Skilled Nursing Benefit *

If Yes, Carrier

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Do you have Life Insurance *

Yes
No

If Yes, Company

Face Value

Cash Value

Beneficiary

Have you applied for Medical Assistance (MA) *

Yes
No

If Yes, when?

Medical Assistance # *

Are you a veteran/spouse of a veteran *

Yes
No

Branch of Service

Do you take prescription medicines *

Yes
No

What is the average monthly cost?

Do you receive medication from the VA? *

Yes
No

Do you have a prescription card? *

Yes
No

What is the type of card? *

Community Contacts

Community Physician *

Phone *

Church Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Funeral Home Preference

Do you have a Burial Trust/Prepaid Funeral? *

Yes
No

Power of Attorney

Have you, or your Power of Attorney, received financial planning services? *

Yes
No

If yes, Name(s) of financial planning service employed by you, or your Power of Attorney

Do you, or your Power of Attorney, have an attorney assisting you? *

Yes
No

If yes, Name of Attorney

Phone

Have you disposed of, or gifted, real estate or personal property within the last 5 years? *

Yes
No

If Yes, list date and explain:

Please be prepared to supply copies of your latest statement for the assets listed below

Please identify if the asset, liability or monthly income are joint or individual, by selecting individual, joint, or spouse in the corresponding column. If this does not apply, please enter $0 for the amount.

Assets

Total Cash *

Cash *

Total Checking *

Checking *

Total Savings *

Savings *

Total Certificates of Deposit *

Certificates of Deposit *

Individual Retirement Accounts, 401K *

Mutual Funds *

Annuitites *

Annuities *

Stocks and Bonds *

Real Estate *

Trust Accounts *

Loans to Others *

Total Assets *

Please add your total amount of assets and place on the line above.

Liabilities

Rent *

Credit Card Debt *

Other Debts *

Mortgage Balance *

Total Liabilities *

Please add your total amount of liabilities and place on the line above.

Monthly Income

Social Security *

Pension *

Annuities *

Investment Income *

Rental Income *

VA Benefits *

Total Monthly Income *

Please add your total amount of monthly income and place on the line above.

Real Estate Owned

Please provide the locations of each property owned and its value.

#1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Estimated Value

Mortgage Balance

#2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Estimated Value

Mortgage Balance

Other Assets

#1 Asset

Fair Market Value

#2 Asset

Fair Market Value

I represent the resources listed above are and will remain available for payment of services I may receive at St. Anne's Retirement Community

Have you ever been convicted of a crime other than a summary offense? *

Yes
No

If Yes, What was the Date of the Conviction

If Yes, Please describe the Conviction

Agreement Signature

I have applied for admission to St. Anne’s Retirement Community. In doing so, I understand that St. Anne’s Retirement Community has a special obligation to clients, Residents and staff with respect to their personal property and safety. I hereby give St.Anne’s Retirement Community the right to make a thorough investigation into my previous employment, education, references, and character, and I release from all liability all persons supplying such information. The investigation is not limited to the above, and criminal checks both State and Federal-can be required. I authorize all public officials or persons involved in reference for admission to furnish information necessary for residency at St. Anne’s Retirement Community. Records obtained will be confidential. I hereby certify that the information and financial statements provided in this application are correct and complete to the best of my knowledge. I understand that any misrepresentation could result in the forfeiture of my application or status as a resident of St. Anne’s Retirement Community, Inc. I understand that this application does not obligate St. Anne’s Retirement Community, Inc., in any way and is submitted to be placed on file, and that the above information is strictly confidential. In the event a resident becomes a danger to themselves and/or others, as in the judgment of the attending physician and Administrator, to jeopardize the health and/or safety of other residents or constitutes a hazard to himself/herself, St. Anne's Retirement Community shall cooperate with the relative or responsible party in finding the most appropriate placement for the Resident.

By choosing I agree, you are legally signing an admission application to St. Anne's Retirement Community. *

I Agree

Type in your name to digitally sign. *

First

Last

Today's Date and Time *

Date

Time

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Care Services at St. Anne’s

Admission Application

Family

#2

#3

Care Preference

Primary Health Insurance (Medicare, Advantage Plan, PPO)

Secondary Health Insurance

Community Contacts

Power of Attorney

Please be prepared to supply copies of your latest statement for the assets listed below

Assets

Liabilities

Monthly Income

Real Estate Owned

Other Assets

Agreement Signature