THE HOUSE OF THE GOOD SHEPHERD 798 Willow Grove Street Hackettstown NJ 07840 (908)684-5900 APPLICATION FOR ADMISSION TO LONG TERM CARE Applicant Name Gender M F Home Address () Code Residence Type House Apartment With Family Senior Housing Assisted Living Nursing Home Name of Facility Home Telephone # E-mail Address If at a temporary location (e.g. hospital or rehab setting) provide name and location. Date of Birth Age Birthplace US Citizen? Y N Marital Status Single Married Widowed Divorced Separated Name of Spouse (if applicable) Social Security Number Religion Ethnicity African American Caucasian Hispanic Asian Name of Church/Synagogue Other Primary Language Prior Occupation Name of person completing application Relationship to applicant How did you learn about The House of The Good Shepherd? Office Use Only: Date Application Received Financial Approval : Date Initials Medical Approval: Date Initials
HEALTH INSURANCE INFORMATION You must submit copies of the front and back of all health insurance cards including Medicare, Medicare Advantage, HMO, Medicaid and any other insurance. You must also provide any notices of eligibility for state or federally-funded programs. Name on Medicare Card MEDICARE Medicare Number Part A Coverage (Date) Part B Coverage (Date) Is Your Medicare coverage provided through a Medicare Advantage Plan? YES NO If yes, Name of Plan Do you have Medicare Part D (Prescription Drugs) Coverage? YES NO Name of Carrier Insurance ID # BIN# PCN# Group# Effective Date If you are not eligible for Medicare, please explain: Name of Insurance OTHER INSURANCE (Medicare Supplement or Other Primary Insurance) Policy (ID) Number Billing Address Who is the Insured? Patient Spouse Name on Policy (if other than applicant) Monthly premium $ Policy Type Individual Group Group Name (if applicable) Group # (if applicable) MEDICAID Medicaid # Medicaid Application Filed? YES NO Date Application Filed Location Application Filed Name of Medicaid Caseworker NJHBID# I am not already enrolled in Medicaid, but I believe I may be eligible: YES NO
CONTACT INFORMATION Please list the names and addresses of family members or others who may be contacted with information and/or in case of emergency. We will be using this information both pre-admission and after the applicant has been admitted. The monthly statement will be sent to the contact listed as responsible party. You must provide copies of Power of Attorney or Advance Directive forms. CONTACT #1 Responsible party Power of Attorney--financial Power of Attorney health care CONTACT #2 Responsible party Power of Attorney-financial Power of Attorney health care
ADDITIONAL CONTACTS CONTACT #3 Responsible party Power of Attorney-financial Power of Attorney health care CONTACT #4 Responsible party Power of Attorney-financial Power of Attorney health care
FINANCIAL INFORMATION (Confidential) TYPE OF INCOME Social Security SSI (Supplemental Security Income) Pension (Name of Company) Trust Other (Type) Other (Type) INCOME MONTHLY AMOUNT CASH AND BANK ACCOUNTS Type of Account Bank Name and Address Account # Account Balance LIFE INSURANCE Company Name and Address Type of Policy Face Value Cash Surrender Value
Description, Name and (if listed) Trading Symbol FINANCIAL INFORMATION (Confidential) STOCKS AND BONDS # of Shares Original Cost Current Value REAL ESTATE Type and Location Type of Interest You Hold Mortgage, if any Value OTHER ASSETS (Include vehicles and other items of value, e.g. coin collections) Type of Asset (Describe) Current Value DEBTS Creditor Name and Address Type of Debt Amount Owed
FINANCIAL INFORMATION (Confidential) PRE-PAID FUNERAL ARRANGEMENTS Name of Funeral Home/Cemetery Value (if revocable) If applicant does not have pre-paid funeral arrangements, you must still provide the name and address of a funeral home for final arrangements: Name of Funeral Home: Location: TRANSFER OF ASSETS Have you transferred, given away, loaned or sold for less than fair market value any cash, bank accounts, stocks, bonds, real estate or other items of considerable value in the past 60 months? YES NO If yes, you must submit verification with this application. LONG TERM CARE INSURANCE YES NO If yes, please provide a copy of the policy. IMPORTANT, PLEASE READ CAREFULLY: Medicare Part A and Part B does not pay for long-term care, such as custodial care in a nursing home. Room and board in long term care is paid with private assets and income, long term care insurance benefits, and/or Medicaid. We must know the source of payment in advance of admission. As an applicant, if you think you may be eligible for Medicaid upon admission or within six (6) months after admission, you must begin the process of applying for Medicaid, which includes qualifying for the program both medically and financially. If you need to apply for Medicaid or need more information about Medicaid eligibility, please contact our Director of Social Services at 908-684-5995. CERTIFICATION OF APPLICATION INFORMATION I hereby represent and certify that that information provided on this application is true and complete. Applicant Date Responsible Party Date rev 05/13