This Application is for: * How did you hear about St. Anne's Retirement Community? Social Security # Email Cell Phone Home Phone * Place of Birth Do you have an Advanced Directive/Living Will? * Do you have a Durable Power of Attorney (POA) for Health Care? * Family
Children/Significant Other (Please list individuals in the order they should be contacted if unable to reach POA)
Relationship * Work Phone Cell Phone * Email #2 Relationship Work Phone Cell Phone Email #3 Relationship Work Phone Cell Phone Email Care Preference To Be Admitted From Residence Hospital Rehab Hospital Health Facility List inpatient Stay Dates for Past Year (Hospital, Other Facility, Transitional Care, etc.) Long Term Care Goal * Return Home Transfer to another Facility/Level of Living Remain at St. Anne's Primary Health Insurance (Medicare, Advantage Plan, PPO) Insurance Company * Policy / ID Number * Group Number (if applicable) * 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 Phone Number Policy/ID # Group Number (if applicable) Annual cost for insurance is Do you have Long Term Insurance? * Phone * Do you have Life Insurance * Have you applied for Medical Assistance (MA) * Are you a veteran/spouse of a veteran * Do you take prescription medicines * Do you receive medication from the VA? * Do you have a prescription card? * Community Contacts Community Physician * Phone * Church Name Phone Funeral Home Preference Do you have a Burial Trust/Prepaid Funeral? * Power of Attorney Have you, or your Power of Attorney, received financial planning services? * Do you, or your Power of Attorney, have an attorney assisting you? * Have you disposed of, or gifted, real estate or personal property within the last 5 years? * 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 * Individual Spouse Joint Total Checking * Checking * Individual Spouse Joint Total Savings * Savings * Individual Spouse Joint Total Certificates of Deposit * Certificates of Deposit * Individual Spouse Joint Individual Retirement Accounts, 401K * Individual Retirement Accounts, 401K * Individual Spouse Joint Mutual Funds * Mutual Funds * Individual Spouse Joint Annuitites * Annuities * Individual Spouse Joint Stocks and Bonds * Stocks and Bonds * Individual Spouse Joint Real Estate * Real Estate * Individual Spouse Joint Trust Accounts * Trust Accounts * Individual Spouse Joint Loans to Others * Loans to Others * Individual Spouse Joint Liabilities Rent * Rent * Individual Spouse Joint Credit Card Debt * Credit Card Debt * Individual Spouse Joint Other Debts * Other Debts * Individual Spouse Joint Mortgage Balance * Mortgage Balance * Individual Spouse Joint Monthly Income Social Security * Social Security * Individual Spouse Joint Pension * Pension * Individual Spouse Joint Annuities * Annuities * Individual Spouse Joint Investment Income * Investment Income * Individual Spouse Joint Rental Income * Rental Income * Individual Spouse Joint VA Benefits * VA Benefits * Individual Spouse Joint Real Estate Owned
Please provide the locations of each property owned and its value.
Estimated Value Mortgage Balance 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? * 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. * Type in your name to digitally sign. *