Residency Application

Fields marked with are required.

Personal Information

First Name

Last Name

Address

City

State

Zip Code

Date of Birth

Age

Social Security No.

Home Phone

Cell/Work Phone

Marital Status

Married

Single

Widowed

Divorced

Emergency Contacts

Emergency Contact #1

Name

Relationship

Address

City, State, Zip

Preferred Phone #

Add another Emergency Contact?

Emergency Contact #2

Name

Relationship

Address

City, State, Zip

Preferred Phone #

Add another Emergency Contact

Emergency Contact #3

Name

Relationship

Address

City, State, Zip

Preferred Phone #

Billing Information (to whom sent)

Name

Relationship

Address

City, State, Zip

Preferred Phone #

Brief Current Medical/Physical Health Information

In the preparer's own words, write a short description of the applicant's condition (impairments, special problems/needs).

Are you or your spouse a Veteran?

Yes

Primary Care Physician (PCP)

PCP Phone #

PCP Fax #

Medicare #

HMO/PPO

Yes

Primary Insurance

Policy #

Secondary Insurance

Policy #

Do you or your spouse have Long Term Care Insurance?

Yes

Policy #

Other

PACE

PACENET

Med D

Policy #

Transfer of Assets

Have you transferred any property, cash, negotiable papers, real estate, etc. to any person with the past five years?

Yes

If yes, description and amount:

Power of Attorney

Living Will/DPOAHC (Durable Power of Attorney for Health Care)

Yes

Person Holding POA

Religious and Social Affiliations

Church Membership

Resident Disclosure

Please check one

I HAVE been convicted of a felony in the past 20 years, and/or been required to be registered for a commission of a sexual offense.

I HAVE NOT been convicted of a felony in the past 20 years, and/or been required to be registered for commission of a sexual offense.

If you marked "I HAVE" above, please briefly explain:

Signature of Applicant or Responsible Party

Signature

Today's Date

The Villas Only

Our average daily rate is $380.00. Knowing this rate and to help facilitate the Medical Assistance Application process, how many months/years can the prospective resident pay privately?

ST. PAUL'S FINANCIAL QUESTIONNAIRE

Are of interest - check all that apply

As part of the application process and as needed thereafter, the following financial eligibility information is required. Please provide copies of statements and documents with this application.

Do you have a health insurance plan?

Yes

If yes, with what company?

Do you have a Medicare D plan?

Yes

If yes, with what company?

Are you or your spouse a Veteran?

Yes

If yes, did you serve during active wartime?

Yes

Do you have Long Term Care Insurance?

Yes

Do you have Life Insurance?

Yes

Do you have a prepaid funeral?

Yes

Do you have PACE or other pharmacy card?

Yes

Do you have a Medicaid Access card?

Yes

Does your monthly income include distributions from assets such as an IRA?

Yes

Do you own real estate?

Yes

If yes, describe the property and location:

Have you transferred any assets during the past five years?

Yes

If yes, describe:

Are any family members willing to help with the cost of your care (where applicable)?

Yes

Monthly Income

Please fill in a dollar amount for each source of income if applicable.

Total monthly income (after Medicare deduction)

Please list sources of monthly income (i.e. Social Security, pension, railroad retirement, Veteran's benefits, annuities, rental property, etc.)

Monthly income from a trust

Real Estate

Please fill in a dollar amount for each source of income if applicable.

Value of Real Estate

Balance of Mortgage and/or Line of Credit

Value of Assets

Please fill in a dollar amount for each source of income if applicable.

Value of checking and savings accounts

Value of retirement assets (certificates of deposit, stocks, bonds, etc.)

Cash value of life insurance policy

Value of Trust

Value of IRA

Value of 401K

Other assets

Please describe your other assets:

Monthly Expenses

Please fill in a dollar amount for each source of income if applicable.

Health Insurance

Pharmacy

Long Term Care Insurance Premiums

Other monthly expenses

Please detail your other monthly expenses:

Certification of Financial Information

Upload Financial Documents

I affirm I have completed this information and to the best of my knowledge and have not withheld any information requested and that statements I have made are true and correct. I also affirm that any misrepresentation regarding my financial assets or any concealment of any other facts as set forth in this application shall be sufficient reason for the rejection of my application or my expulsion from St. Paul Homes, if accepted as a resident or Without Walls client. I further certify that all of these assets will be available for the costs of care and expenses at St. Paul Homes. Any major reduction of assets will be verified before my residency at St. Paul Homes.

Signature of Person Completing Application

Relationship

Phone #

Today's Date