Please note missing information and documentation will delay approval or result in denial.

Transcription

1 Thank you for choosing Stella Maris for Long Term Care Please note missing information and documentation will delay approval or result in denial. The Application must be completed entirely: First four pages consist of demographic, insurance, and financial information. Please sign page 4. Do not leave any blanks; non applicable information should be marked as N/A. Authorization for Disclosure of Protected Health Information (PHI) by an authorized decision maker or representative. Complete the top section, leave middle blank, and sign on the bottom for permission to request medical records. A separate sheet is included to list all doctors, providers, and/or facilities that have provided care for the applicant. Medical Assistance Verification list is for applicants anticipating applying for assistance to help pay for room and board. Please provide all documents on the Verification List to our accounting office. This is required to determine eligibility. Supporting documentation: o Copies of all insurance cards (front and back), including Medicare, secondary insurance, and a prescription plan o Power of Attorney documentation (financial & medical) if applicable o Living Will and/or Advance Directive if applicable o Private pay applicants must provide the most recent financial statement(s) that reflect current assets (for applicants with assets greater than or equal to $125,000) o Applicants anticipating Maryland Medical Assistance (Medicaid) must provide copies of all documents listed on the Medical Assistance Verification list to determine eligibility (for applicants with less than $125,000) o Applicants with Medicaid at another Long Term Care facility must provide either 6 months of bank statements or 6 billing statements from current facility and medical assistance number. o Mercy Ridge residents must provide a current Mercy Ridge deposit statement if deposit is greater than $100,000 if applicant intends to use these funds to pay for monthly expenses at Stella Maris. Paperwork must be signed at Mercy Ridge for direct billing upon admission o Applicants working with an elder care attorney for Medical Assistance must advise their attorney to provide a letter of representation and the cost of care. Letters should be sent to Pam Burns (pburns@stellamaris.org) and to Randi Jones (rjones6@stellamaris.org) Applications can be submitted one of the following ways: Mail to ATTN Admissions 2300 Dulaney Valley Rd. Timonium, MD FAX to to Pam Burns at pburns@stellamaris.org Drop off by the Admissions Office Please call ext for additional information and/or application status. You may also visit our website at to access information about our facility. Page 1 of 9

2 ADMISSIONS APPLICATION All sections must be completed or the application will be considered incomplete. Incomplete applications will be an automatic denial for Long Term Care. If you need help completing this application, call the Admissions Office at , ext Name of Applicant Phone Number Applicant Current Address City/State/Zip Current Applicant Location City/State/Zip CONTACTS Name - Medical Contact (Relationship to applicant) Home Phone Work Phone Address Cell Phone City/State/Zip Address Name - Financial Contact (Relationship to applicant) Home Phone Work Phone Address Cell Phone City/State/Zip Address HEALTH INSURANCE INFORMATION (Please Provide front & back card copies) Medicare # Part A Part B Social Security # Commercial Insurance Policy # Medicare Part D Plan Policy # Medicaid # Effective Date Long Term Care Insurance # Effective Date Page 2 of 9

3 Birth Date: U.S. Citizen: Yes No Sex: Male Female Marital Status: Married Widowed Single Divorced Separated Race: Religion: Veteran: Yes /No Branch of Service: LIFE INSURANCE Policy Number Company Face Value Cash Value MONTHLY INCOME: (Fill in all that are appropriate) If married, provide spouse's income. Source Applicant Spouse Source Applicant Spouse Social Security Interest Income Pension Rental Income Veteran's Benefit Reverse Mortgage Disability Other SSI Totals Totals TOTAL MONTHLY INCOME: $ Medical Assistance applications require 5 years of bank records, CD s, stocks, Federal tax returns. All financial data with patient s name, whether individually/jointly, open or closed accounts, must be provided to be approved financially. Medical Assistance requires patient to contribute a part of the monthly income towards the cost of care. Checking Item ASSETS #1 (Assets for Applicant/Spouse/Joint) Applicant Spouse $ Amount $ Amount Joint $ Amount Savings CD's/Stocks/Bonds (cash value) IRA's Prepaid Funeral Arrangement Page 3 of 9

4 ASSETS #1B ACCOUNTS CLOSED WITHIN LAST 5 YEARS (Assets for Applicant/Spouse/Joint) Item Date Closed Amount Transferred Transferred to? Checking Savings CD's/Stocks/Bonds (cash value) IRA's Prepaid Burial Plot ASSETS #2 PROPERTY OWNED (Include Rental/Commercial/Out-of-State Property) Ownership Equity Amount Mortgage Property #1 Property #2 Property #3 Mobile Home Time Share Land #1 Land #2 ASSETS #2B PROPERTY SOLD WITHIN LAST 5 YRS (Include Rental/Commercial/Out-of-State Property) Ownership Date Sold $ Amount Property #1 Property #2 Property #3 Time Share Mobile Home Land #1 Land #2 GIFTS/TRANSFERS IN PAST 5 YEARS (Must be thoroughly explained.) Gift Amount Date To Whom Checking Account Savings Account Property CD's IRA's Stocks Other TOTAL GIFTS/TRANSFERS IN PAST 5 YEARS Page 4 of 9

5 EXPENSES Expense Yes No Amount Liens/Garnishments IRS Liens/Garnishment Credit Card Debt Car Payment Bankruptcy Healthcare Agency/ Private Duty Expense TOTAL EXPENSES Are you working with an Eldercare attorney for Long Term Care Placement? Yes No Name of Attorney: Phone: See Application Letter for details on required supporting documents. I attest that I have truthfully answered all questions and have accurately listed all assets, insurance and other financial information. Providing false information or inaccurate information will make this application null and void and will deny admission approval. Signature: Date: At Stella Maris, no person shall, on the grounds of race, color, religion, age, sex, sexual orientation, national origin, ancestry, disability, veteran status or genetic information, be excluded from participation in, be denied benefits of or otherwise be subject to discrimination in the provision of any care, service or admission. Referred by: Family/Friends Hospital Website Physician TV Other Page 5 of 9

6 Please list applicant s health care providers. This will allow the admissions nurse to request medical records from appropriate parties to complete the medical review. Primary Care Physician: Name: Address: Telephone: Fax: Specialist(s): Type (i.e. cardiologist, neurologist, etc.): Name: Address: Telephone: Fax: Type (i.e. cardiologist, neurologist, etc.): Name: Address: Telephone: Fax: Type (i.e. cardiologist, neurologist, etc.): Name: Address: Telephone: Fax: Facility: Has the applicant been admitted to and/or resided at any facility within 6 months (i.e. hospital(s), Emergency Department, assisted living, and/or rehab facilities, etc.)? Facility Name: Dates: to Reason: Facility Name: Dates: to Reason: Page 6 of 9

7 Authorization for Disclosure of Protected Health Information (PHI) Specific Provider or Medical Facility (List all requested providers and facilities) Patient Last Name Patient First Name Patient Middle Initial Social Security Number Date of Birth Medical Record Number Street Address City State/Zip Code Home Phone Number Work Phone Number Mobile Phone Number I, the undersigned, hereby authorize the above named provider or medical facility to disclose in writing to the individual, entity, facility or company named below my PHI contained in my medical record. I further authorize the above named provider or medical facility to disclose my PHI electronically and/or discuss my PHI verbally with the individual, entity, facility or company named below. I hereby authorize the disclosed PHI to include (check ALL that apply): Hospital Discharge Summary Physician Orders Current Med List History and Physical Progress Notes Nurse s Notes Radiology Report Chest X-ray Please release records covering the time period: (MM/DD/YYYY to MM/DD/YYYY) to Information to be disclosed to: STELLA MARIS, INC. ADMISSION OFFICE FAX: Purpose of Disclosure: Admission into Long Term Care at Stella Maris, Inc. The PHI provided under this authorization may include diagnosis and treatment information, including information pertaining to chronic diseases, behavioral health conditions, alcohol and substance abuse, communicable diseases (including HIV/AIDS) and/or genetic marker information. I understand and agree to the following: Mercy Health Services does not condition health care treatment I am otherwise entitled to on whether I sign this authorization. I understand that the medical records to be accessed may contain medical information pertaining to psychiatric, drug and/or alcohol, HIV/AIDS diagnosis and treatment. This authorization will expire one (1) year after the date of my signature below unless a shorter time period is stated here:. (Must be a time period or date, not an event or condition). Information used or accessed under this authorization may be re-disclosed by the recipient and no longer protected by Federal law, but may be protected under Maryland law. I am free to revoke this authorization at any time by submitting a written request to the entity/provider disclosing the PHI. Any uses or disclosure of my PHI prior to receipt of the revocation cannot be reversed and will not be covered by the revocation. Signature of Patient (or Legally Appointed Representative) Date Print Name of Legally Appointed Representative (if applicable) Documentation establishing authority of Legally Appointed Representative (Duly appointed Personal Representative, Health Care Power of Attorney, Advance Directive, Parent of Minor Child, etc.) Page 7 of 9

8 LONG TERM CARE MEDICAL ASSISTANCE VERIFICATION LIST Applicant's Name: DSS Office: The following documents must be produced by (Date) Date Applied to DSS: in order to determine Medicaid Finance Eligibility. Rec'd Pending N/A Signed and dated Long Term Care Medical Assistance Application* Signed and dated Representative's Statement* Signed and dated Consents for Release of Information (2)* Signed and dated Voter's Registration* Verification of Applicant's Birth: Birth Certificate/Baptismal Certificate or Letter from Social Security Administration noting Applicant's Date of Birth Alien Status, i.e., INS Letter, INS Alien Registration Card, Certificate of Naturalization Certificate of Citizenship Photo ID (Federal, State or Local Government ID, Driver's License, U.S. Passport or Military ID Social Security Card or 1099 Medicare Card or Letter from Social Security Administration Copy of Secondary Health Insurance Card - Need front and back. Verification of secondary health insurance premiums/bills Verification of secondary health insurance payment - Cancelled check or paid receipt Verification of monthly income: Social Security/Pension/Annuity/Veterans Benefits Verification of Marital Status: Marriage License, Separation Documents, Divorce Decree or Death Certificate Irrevocable Prepaid Itemized Burial Contract Deed(s) to all property including Burial Plots and Vaults Current Face, Cash and Dividend Value of all Life Insurance Policies Durable Power of Attorney, Financial Power of Attorney or Guardianship Verification of all Transfers/Gifts within the last 5 years (Cancelled checks required.) All Bank Account(s) Statements for the past 5 years: checking/savings/joint accounts Closed Account(s) Statements for the past 5 years: checking/savings/joint accounts *The first four (4) items must be completed with the Stella Maris Medical Assistance Eligibility Coordinator. Signature: Representative Date Medical Assistance Eligibility Coordinator Date Page 8 of 9

9 LONG TERM CARE MEDICAL ASSISTANCE TO BE ELIGIBLE FOR LONG TERM CARE MEDICAL ASSISTANCE, THE APPLICANT MUST QUALIFY BOTH FINANCIALLY AND MEDICALLY. FINANCIALLY The applicant must have less than $2, in total assets if single. Examples of assets are checking/savings accounts, IRA's, CD's, money market, 401K, any joint accounts. Property includes primary home, vacation homes, rental property, motor homes. Life insurance policies: Cash value of all policies. Please note a cash value of a policy can make an individual over scale for Long Term Care Medical Assistance. Any transfer of assets in the past 5 years must be provided. Example of asset transfers are gifting of money and property to family members and to non-family members. Transfers of assets within the past 5 years will cause penalties to occur with Medical Assistance and can make you financially ineligible. All penalties must be resolved to qualify financially. MEDICALLY The Resident must qualify for a Nursing Facility Medical Level of Care. Medical Eligibility is determined by Delmarva Foundation and it is based on the current medical needs of the resident. IT IS THE RESPONSIBILITY OF THE RESIDENT'S REPRESENTATIVE TO APPLY AND PURSUE MEDICAL ASSISTANCE BENEFITS. HOWEVER, THE MEDICAL ASSISTANCE ELIGIBILITY COORDINATOR IS AVAILABLE TO ASSIST YOU THROUGH THE PROCESS OF APPLYING FOR BENEFITS. FAILURE TO PROVIDE THE REQUIRED LONG TERM CARE MEDICAL ASSISTANCE INFORMATION TIMELY AND ACCURATELY WILL RESULT IN DENIAL OF ADMISSION AND/OR DISCHARGE FROM FACILITY. Page 9 of 9