Get Application For Nursing Facility Applicant ... - Chsbuffalo

Completing the application for a nursing facility can seem daunting at first, but this guide will provide you with clear, step-by-step instructions to help you navigate the process. Ensuring that all information is accurately recorded is essential for a smooth admission process.

Follow the steps to complete your application accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the applicant demographics section, which includes the name, date of birth, home address, city, county, state, zip code, and telephone number. Also, indicate the applicant's gender and marital status.
3. Provide the applicant's present location and indicate whether they have previously stayed in a nursing facility. If yes, include the facility name and the dates of stay.
4. In the responsible persons section, input the financial representative's name, relationship to the applicant, address, and telephone numbers. Indicate if there is a bank power of attorney, durable power of attorney, committee of estate, or any conservatorship or guardianship.
5. Fill out the designated representative's information in a similar manner as the financial representative, including their name, relationship, address, and contact numbers.
6. In the insurance coverage section, indicate the applicant's veteran status, medicare and medicaid information, long term care insurance, and any other medical insurance details.
7. Provide the name and address of the attending physician.
8. Document the applicant's monthly income sources, including salary, social security, retirement pensions, and any other income. Provide the total monthly income for both the applicant and their spouse, if applicable.
9. Next, indicate the assets owned by the applicant, such as real estate, life insurance, or pre-paid funeral plans. Fill out any additional assets including checking and savings accounts, and provide their approximate values.
10. Document any liabilities the applicant may have, including home mortgages or loans, and provide their approximate values.
11. In the placement preferences section, indicate your preference for specific nursing facilities or if you are open to any facility.
12. Finally, review the acknowledgment statement regarding the reliance on the information provided for the admission decision. Sign and date the application appropriately.
13. Once all sections are complete, be sure to save any changes made, and choose to download, print, or share the form as necessary.

Start filling out your application for the nursing facility online today to ensure timely processing.