In order to complete the application, a copy of the following documents must be provided:
- Medicare Card
- Living Will/Advanced Directive
- Medicaid Card
- Social Security Card
- Private Insurance Card
- Power of Attorney – Medical and Finance
* Indicates required information
Home Address of Spouse/Responsible Party: *
Spouse/Responsible Party Telephone Numbers:
If resident is unable to make financial/medical decisions, who is responsible?
Additional Relatives/Significant Others:
The following information is required concerning the Resident’s finances. Please indicate the resources which are available to pay for the cost of the care. The information supplied will be strictly confidential and will be used to assist you in your long-term planning.
It is the policy of Levindale Hebrew Geriatric Center and Hospital to collect the equivalent to one month’s room charge in advance and at the beginning of each subsequent month. Resident bills owed monthly and the amount due is payable upon receipt. Amounts unpaid by the end of the month will be subject to late charge as provided in the Admissions Agreement.
PLEASE SIGN BELOW
I hereby affirm that, to the best of my knowledge, the financial information provided is accurate and complete and the assets listed are available to pay for the Resident’s care at Levindale Hebrew Geriatric Center and Hospital. The nursing center has my permission to obtain a credit report of the application or contact the financial institutions listed herein.