Leeway - Leaders in AIDS Care

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PART I: PERSONAL INFORMATION

Applicant's Name *

Age *

Address *

Active Home Phone *

Active Cell Phone *

DOB *

Sex *

Religion *

Social Security # *

Medicare # *

Medicaid # *

Other Insurance

Physician’s Name *

Phone *

Address

Nearest Relative/Responsible Party

Relationship

Phone

Address

Other Contact

Relationship

Phone

Does someone hold the applicant’s Power of Attorney?

Yes

Name

Phone

Address

Does the applicant have a conservator?

Yes

Name

Phone

Address

Date

PART II: AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize release of medical information pertaining to the above applicant to Leeway Residential Care Facility.

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Signature is required.

Signature of Applicant or Responsible Party

Date *

PART III: APPLICANT’S FINANCIAL INFORMATION

Name *

Date *

INCOME

Social Security

per month

SSI

SSD

Pension

per month

from

Annuity

per month

from

Interest/Dividends

per month

from

Veterans Benefits

per month

from

Other

per month

from

Textarea

Do you receive income from or have any interest in a trust? If yes, please describe and provide a copy of the trust document.

Yes

ASSETS

Own Home?

Yes

Jointly held?

Yes

Value

Other property?

Yes

Jointly held?

Yes

Value

Stocks/Bonds?

Yes

Jointly held?

Yes

Value

Life Insurance?

Yes

Jointly held?

Yes

Value

Funeral Insurance?

Yes

Jointly held?

Yes

Value

Other?

Yes

Jointly held?

Yes

Value

BANK ACCOUNTS

Owner(s) of Account

Present balance

Address

Bank Name

Owner(s) of Account

Present balance

Bank Name

Address

PART IV: TRANSFER OF ASSETS

1. Has the applicant sold or given away a motor vehicle, property, stocks, bonds, cash, or any other significant assets in excess of $1,000 in the past two years?

Yes

Please describe

2. Has any type of trust been established in the last two years prior to this application?

Yes

Please describe

PART V: PAYMENT SOURCE

Payment to Leeway, Inc. for room and board will be made by

Personal funds

Title 19 ( Medicaid)

SAGA

Unknown

(select one)

Medicaid Number

(if applicable)

SAGA Number

(if applicable)

Has the applicant applied for Title 19 (Medicaid) Assistance?

Yes

If yes, name of intake worker

Phone

Redetermination review date

(Redetermination cycle: 6 months or yearly)

I hereby certify that the information submitted in this application is complete and accurate.
I understand that misrepresentation is a basis for both denial of admissions or discharge.

Applicant’s Signature

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Date

Signature of Responsible Party/Relative

Reset Signature

Date

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Residential Care Home Application

If you would prefer to download the application and fill it out, please click here to DOWNLOAD the file