• Instructions

• It is appreciated if you would be as complete as possible when answering these questions. Answering all questions allows our Admissions Office to process your application as quickly as possible and to help serve you efficiently.

  ADMISSIONS APPLICATION:
  Prior to admission you’ll be asked to provide copies of the following documents which may pertain to your loved one. Failure to provide copies of these documents may result in an admission delay.

• Social Security Card
• Medicare Card
• Medicaid Card
• Major Medical Insurance Card
• Medicare D Prescription Plan
• Body Organ Donor Card
• Long-term Care Insurance Card
• Power of Attorney Form
• Living Will/Health Care Proxy

Everyone is encouraged to call your insurance carrier directly to obtain details regarding your specific insurance coverage and benefit package. It is important to note that if you have benefits, you still must meet criteria / qualifications set forth by your insurance carrier. You should be aware, in advance, of placement of any potential deductibles and/or co-payment requirements. All long-term residents of Fairport Rehab & Nursing Center are required to appoint a Power of Attorney and have a Health Care Proxy.

Please be sure to give us the name and complete address of your current Physician (and other Specialists) so medical information may be obtained prior to admission. Your signature at the end of this form is necessary in order to obtain medical information from a phyisicain's office, hospital, and /or/clinic. Copies of this form may be included with letters requesting information on your medical condition.

• Personal Information

• Full Name*
  Please type you full name including any salutations or titles.
• Birth Date*
  MM slash DD slash YYYY
• Birth Place
• Are you a US Citizen*
  • Yes
  • No

• ---

• Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
• How long at this address?
• Email*
• Phone Number

  If you need additional rows, please click the + below.

  Number	Type

• ---

• Marital Status:
  • Married
  • Widow
  • Widower
  • Single
  • Divorced
• Spouse's Name*

• ---

• Are You a Veteran?
  • Yes
  • No

• ---

• Contact Persons:*
  (Nearest Relatives or Significant Others). Please list in order of contact. Please indicate if the individual is your Power of Attorney (POA) or Health Care Proxy (HCP).

  If you need additional rows, please click the + below.

  Name	Relationship	POA	HCP	Primary Phone	Work Phone	Email Address	Full Address (include city, state and zip code)

• ---

• Medicare #
• Medicaid # (if applicable)
• CIN #
• County

• ---

• How long do you expect to be self-pay?
  (We do require some basic financial information for all active long-term applicants)

• ---

• Health Insurance Coverage*
• Contract #*
• List any other Insurance
  (e.g.: MVA, Workers' Compensation)
• Contract / Claim #
• Name and Address of Representative
• Do You Have a Long-term Care Insurance Policy?
  • Yes
  • No
• Company
• Contract #
• Medicare D Prescription Plan Coverage Company

• ---

• Church Membership
• Denomination

• Financial Information

• Monthly Income
  Please provide monthly dollar amount for income.

  If you need additional rows, please click the + below.

  Source of Income	Type of Income (if other)	Applicant	Spouse (if applicable)

• ---

• Trust
  Please indicate if a Trust has been established
  • Yes
  • No
• Date of Trust
  MM slash DD slash YYYY
• Is it:
  • Irrevocable
  • Revocable

• ---

• Burial Fund
  Has a burial Fund/Trust already been established?
  • Yes
  • No

• ---

• Liquid Assets
  (Liquid Asssets are monies which can be liquidated and utilized for Applicants care). If a Trust has been established please check which assets are included in the Trust in the right column.

  If you need additional rows, please click the + below.

  Account Type	Location	Amount	Included in Trust?

• ---

• Real Estate
  If you need additional rows, please click the + below.

  Property Location	Owners listed on deed	Value	Included in trust?

• ---

• Long-Term Care Policy
  If you need additional rows, please click the + below.

  Company Name	Policy Number	SNF Benefit details

• ---

• Liabilities
  Please list outstanding debts (e.g. mortgage, loans, credit card, real estate)

  If you need additional rows, please click the + below.

  Liability	Amount Owed

• ---

• Asset Transfer
  Current look back period when applying for Medicaid is five (5) years. It is important to know that transfers of assets within this look back period could potentially result in penalty or denial of Medicaid eligibility by the Department of Social Services. Assets can not only be monetary but real estate, land, stocks and investments.

  If you need additional rows, please click the + below.

  Asset Transferred	Transferred To	Amount of Transfer

• ---

• Has a Medicaid application been submitted on behalf of the applicant?
  • Yes
  • No
• Date of application submission
  MM slash DD slash YYYY
• County
• Name of Case Worker
• Phone

• Signature / Confirmation

• Total Resources of Applicant
  I hereby declare that the statement of assets and monthly income levels are true to the best of my knowledge and belief. Upon completion of the form, I acknowledge that the total of the applicants resources is as listed below and these assets/monies will be utilized for the services and care provided by the Fairport Rehab & Nursing Center.

• It is mandated that the Fairport Rehab & Nursing Center be notified three (3) months prior to the exhaustion of resources available for the applicants care so that hte Medicaid application can be initiated. The Fairport Rehab & Nursing Center reserves the right to request additional financial information including, but not limited to, copies of financial statements and/or the most recently completed 1089 form(s).

  Please be advised that upon admission to the Fairport Rehab & Nursing Center skilled nursing that a security deposit equal to one months' (30 days) private room rate is required for all private pay Residents.

• I agree to the terms as described above*
  • Yes
  • No
• Signature of Power of Attorney / Responsible Party*
• Print Name*
• Date*
  MM slash DD slash YYYY

• This document can not be submitted if you do not agree and sign.

• Name
  This field is for validation purposes and should be left unchanged.