Residential Care Home Application If you would prefer to download the application and fill it out, please click here to DOWNLOAD the file If you are human, leave this field blank.PART I: PERSONAL INFORMATIONApplicant's Name *Age *Address *Active Home Phone *Active Cell Phone *DOB *Sex *Religion *Social Security # *Medicare # *Medicaid # *Other InsurancePhysician’s Name *Phone *AddressNearest Relative/Responsible PartyRelationshipPhoneAddressOther ContactRelationshipPhoneDoes someone hold the applicant’s Power of Attorney?YesNoNamePhoneAddressDoes the applicant have a conservator?YesNoNamePhoneAddressDatePART II: AUTHORIZATION FOR RELEASE OF INFORMATIONI authorize release of medical information pertaining to the above applicant to Leeway Residential Care Facility. *Reset SignatureSignature is required.Signature of Applicant or Responsible PartyDate *PART III: APPLICANT’S FINANCIAL INFORMATIONName *Date *INCOME Social Securityper monthSSISSDPensionper monthfromAnnuityper monthfromInterest/Dividendsper monthfromVeterans Benefitsper monthfromOtherper monthfromTextareaDo you receive income from or have any interest in a trust? If yes, please describe and provide a copy of the trust document.YesNoASSETS Own Home?YesNoJointly held?YesNoValueOther property?YesNoJointly held?YesNoValueStocks/Bonds?YesNoJointly held?YesNoValueLife Insurance?YesNoJointly held?YesNoValueFuneral Insurance?YesNoJointly held?YesNoValueOther?YesNoJointly held?YesNoValueBANK ACCOUNTS Owner(s) of Account Present balanceAddress Bank Name Owner(s) of Account Present balanceBank Name Address PART IV: TRANSFER OF ASSETS1. 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?YesNoPlease describe2. Has any type of trust been established in the last two years prior to this application?YesNoPlease describePART V: PAYMENT SOURCEPayment to Leeway, Inc. for room and board will be made byPersonal funds Title 19 ( Medicaid) SAGAUnknown(select one)Medicaid Number(if applicable)SAGA Number(if applicable)Has the applicant applied for Title 19 (Medicaid) Assistance?YesNoIf yes, name of intake worker PhoneRedetermination 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 SignatureReset SignatureDateSignature of Responsible Party/RelativeReset SignatureDateCaptcha *reCAPTCHA is required.Submit
