Admissions Application – St. Luke's Home

Applicant Information

First

Middle

Last

Preferred Name

Sex

Male

Female

Birthday

Placement Needed

Immediate

Within 6 months

Unknown

Anticipated Stay

Short Term

Long Term

Unknown

Room Preference

Shared

Private ($20/day extra)

Civil Status

Full Name of Spouse

Date of Marriage

Applicant's Present Address

City

State / Province / Region

ZIP / Postal Code

Country

Prior Occupation

Retirement Date

Applicant's Present Phone Number

Place of Birth

MEDICARE

Number

Note: Copy of Medicare card needed upon admission.

Part A

Part B

Part A & B

Other Insurance

Secondary

Policy #

Secondary

Policy #

Prescription Drug Coverage

Name

ID #

Name

ID #

County Assistance

Yes

No

County #

No, but information regarding application needed:

VETERANS’ AFFAIRS

Is the applicant a Veteran?

Yes

No

Branch of Service

War(s) Served In

Do you receive any VA benefits?

Yes

No

BILLS TO BE MAILED TO

First Name

Last Name

Phone

Address

City

State / Province / Region

ZIP / Postal Code

Country

PHYSICIAN

Pharmacy

Thrifty White Drug

Clinic Pharmacy

SPIRITUAL/CHURCH

DENTIST

FUNERAL HOME

EYE DOCTOR

ADVANCED DIRECTIVES

Check applicable boxes, provide copies of applicable paperwork upon admission.

Power of Attorney (POA)

Durable Power of Attorney (DPOA)

Power of Attorney for Healthcare

Living Will

Guardian/Conservator

Name of DPOA/POA/Guardian

EMERGENCY CONTACT

First

Middle

Last

Preferred Name

Relationship

Address

City

State / Province / Region

ZIP / Postal Code

Country

Home Phone

Work Phone

Cell Phone

Email

EMERGENCY CONTACT

First

Middle

Last

Preferred Name

Relationship

Address

City

State / Province / Region

ZIP / Postal Code

Country

Home Phone

Work Phone

Cell Phone

Email

EMERGENCY CONTACT

First

Middle

Last

Preferred Name

Relationship

Address

City

State / Province / Region

ZIP / Postal Code

Country

Home Phone

Work Phone

Cell Phone

Email

EMERGENCY CONTACT

First

Middle

Last

Preferred Name

Relationship

Address

City

State / Province / Region

ZIP / Postal Code

Country

Home Phone

Work Phone

Cell Phone

Email

EMERGENCY CONTACT

First

Middle

Last

Preferred Name

Relationship

Address

City

State / Province / Region

ZIP / Postal Code

Country

Home Phone

Work Phone

Cell Phone

Email

Application Information

Reason applicant needs skilled care:

Dementia/Memory Care

Physical Condition

Height

Usual Weight

Weight

List any Known Drug/Food Allergies

Dentures

Yes

No

Eye Glasses

Yes

No

Hearing Aides

Yes

No

Mental Status:

Do you have a Substance Use Disorder(Alcohol/drugs)

Yes

No

List Prior Surgeries in last 100 Days

Any Falls in last Month/How Many & When

Does Applicant

(mark all that apply)

Language(s) Spoken by Applicant

Hobbies/Interests (past or present)

List any Clubs/Organizations applicant belongs to (past/present)

Highest level of education complicated

Has applicant previously voted in North Dakota?

Yes

No

Does applicant wish to vote?

Yes

No

List of Applicant's Children

You must complete the following UNLESS applicant is full VA Contract or has been Approved for Medicad. If skipping, scroll to the end of application for signature.

1. List all the transfers or gifts of assets with the past five years by you and your spouse, including transfers of a remainder interest in real property.

Date of Transfer

Description of Asset

Recipient of Asset

Value of Asset

Date of Transfer

Description of Asset

Recipient of Asset

Value of Asset

Date of Transfer

Description of Asset

Recipient of Asset

Value of Asset

2. List all pre-paid burial contracts, burial accounts, and pre-paid burial or funeral items owned by you or your spouse or by a third party for the benefit of you or your spouse.

Description

Owner

Value

Description

Owner

Value

3. List all sources of income for you and your spouse, including but not limited to rental payments, CRP income, long-term care insurance benefits, Social Security benefits, veteran’s benefits, and employment income.

Description

Date or Frequency of Payment

Amount of Payment

Description

Date or Frequency of Payment

Amount of Payment

Description

Date or Frequency of Payment

Amount of Payment

Description

Date or Frequency of Payment

Amount of Payment

Description

Date or Frequency of Payment

Amount of Payment

4. Except for personal effects, list all assets owned by you and your spouse, including the cash surrender value of life insurance, stocks, bonds, vehicles, life estates, and pensions, with the value as of the date of admission into the nursing home. (Attach additional pages if needed.)

Checking Account

Savings Account

CDs/IRAS/Annuities

Stocks/Bonds/Mutual Funds

Life Insurance (cash surrender value)

Real property (Home, Land, Rental Property)

Life Estate(s)

Vehicles (car, truck, motor home, snowmobile, motorcycle, boat, etc.)

Trusts (own or are a beneficiary of)

Mineral Rights (oil, gas, coal, etc.)

Future Income

Do you or your spouse have any pending legal action from which you may receive money, including an inheritance or a settlement?

Yes

No

If yes, please describe:

Employment

Are you or your spouse employed by another?

Yes

No

If yes, provide the name of the employer, hours worked, and the wage or salary earned:

Are you or your spouse self-employed?

Yes

No

If yes, list who, nature of business, and date business started:

Are you or your spouse actively engaged in farming?

Yes

No

Do you or your spouse have an ownership interest in a business?

Yes

No

If yes, please describe the nature of the business and extent of ownership: