Assisted Living

Moving into a senior community doesn’t mean the loss of independence. Park Avenue Villa provides you with a caring and supportive environment that helps you maintain your independence and enjoy a carefree lifestyle. We offer comfortable living, convenience and a homelike atmosphere with your comfort in mind. Trained staff members are available to assist with personal needs, including bathing, dressing, grooming, and medication administration.

Our assisted living building is security-controlled for your safety and wheel-chair accessible, with an elevator for upper level units. Common areas include a fours-season room for meetings or parties, relaxing sitting areas with a fireplace, library and a large dining room. A licensed beauty shop is also on site.

Contact Beth Urbanec, Park Avenue Villa Director at (701) 483-3000 or PAV@stlukeshome.com for more information.

Online Admission Application

Application for Admission

Step 1 of 3

Applicant Information
Full Name
First: Middle: Last: Preferred:
SEX:
- male
- female
Date of Birth:
MM slash DD slash YYYY
SOCIAL SECURITY #:
Placement Needed:
- immediate
- within 6 months
- unknown
Anticipated Stay:
- short term
- long term
- unknown
Room Preference:
- Shared
- Private ($15/day extra)
CIVIL STATUS:
- Married
- Never Married
- Widowed
- Divorced
- Separated
Name of Spouse:
First: Middle: Last:
Date of Marriage:
MM slash DD slash YYYY
Applicant's present address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Applicant's present phone #:
Prior occupation & Retirement Date:
MM slash DD slash YYYY
Place of Birth:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
MEDICARE
Number:

Note: Copy of Medicare card needed upon admission.
- Part A
- Part B
- Part A and B

OTHER INSURANCE

Secondary	Policy #:	Third	Policy #:

PRESCRIPTION DRUG COVERAGE

Name:	ID #:

COUNTY ASSISTANCE
- Yes
County #:
- No
- No, but information regarding application needed:
VETERANS’ AFFAIRS
Is the applicant a Veteran?
- First Choice
- Second Choice
- Third Choice
Branch of Service
War(s) Served In
Do you receive any VA benefits?
- Yes
- No
BILLS TO BE MAILED TO
Name:
First Last
Phone:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
PHYSICIAN:
Pharmacy
- Thrifty White Drug
- Clinic Pharmacy
Choose 1
SPIRITUAL/CHURCH:

(Church/religion)
DENTIST:
EYE DOCTOR:
FUNERAL HOME:
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:
APPLICATION CONTINUED ON NEXT PAGE

You must complete this page UNLESS applicant is full VA Contract or has been Approved for Medicad
Name
First Name: Initial: Last:
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

A	B	C

Description of Asset

A	B	C

Recipient of Asset

A	B	C

Value of Asset

A	B	C

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

A	B

Owner

A	B

Value

A	B

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 of Income

A	B	C	D	E

Date of Frequency of Payment

A	B	C	D	E

Amount of Payment

A	B	C	D	E

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.)

Amount of Payment

A	B	C	D	E	F

Description of Asset

Checking Account	Savings Account	CDs/IRAS etc	D	E	F

Balance/Value

A	B	C	D	E	F

This questionnaire complies with section 50-24.1-22 of the North Dakota Century Code. By my signature below, I hereby authorize the nursing home to contact the country social services for information regarding any Medicaid application and eligibility, and I hereby release and authorize the country social services to release any information to the nursing home. I also authorize the nursing home to contact any and all of the above-identified financial institutions to obtain information regarding my assets and income, and I hereby release and authorize the financial institutions to release any information to the nursing home. I further authorize the nursing home to release to its attorneys any information regarding my application for admission.

I understand that providing false information could result in discharge and/or denial of my application. The answers provided herein are true and correct to the best of my knowledge and information.
Signature:
Date:
MM slash DD slash YYYY
CAPTCHA

Apartment Amenities

Services

included in rent:

Continental breakfast and Noon meal. (Supper available at additional charge)
Daily tenant checks
Weekly housekeeping and linen services
Social programs
Exercise & yoga programs
Maintenance Services
ER call pendant
Basic internet/Wi-Fi
Worship services and spiritual activities
Complimentary laundry facilities

Personal Care Service

options include:

PHONE: Home	Work:	Cell:	Email:

PHONE: Home	Work:	Cell:	Email:

PHONE: Home	Work:	Cell:	Email:

PHONE: Home	Work:	Cell:	Email:

Application for Admission

Step 1 of 3

Applicant Information

MEDICARE

VETERANS’ AFFAIRS

BILLS TO BE MAILED TO

ADVANCED DIRECTIVES

APPLICATION CONTINUED ON NEXT PAGE

Emergency and Family/Representative Numbers and Addresses

EMERGENCY CONTACT

Application Information

You must complete this page UNLESS applicant is full VA Contract or has been Approved for Medicad

Apartment Amenities

Services

Personal Care Service

Contact Us

Height	Current Weight	Usual Weight