Long-term Care

Skilled Care

St. Luke’s Home provides skilled care (also called nursing home care or skilled nursing care) for individuals who require ongoing long-term care.

Moving into a skilled nursing center can be one of the most important and positive decisions you can make for yourself or your loved one. At St. Luke’s, your quality of life is improved with assistance with daily living activities, professional medical services, therapy, dietary assistance, and life enrichment activities. You deserve to be cared for by professionals with resources designed to meet your needs – including 24/7 clinical oversight and care, medication management, therapeutic social interactions and more. We encourage and assist individuals to live with dignity and promote their independence.

St. Luke’s Home participates in the Medicare and Medicaid programs and accepts both private and long-term care insurance as appropriate

Contact:

Tasha Rohde, Admission Coordinator/Case Manager at (701) 456-8259 or by tjensen@stlukeshome.com

Aileen Paluck, Social Services at (701) 456-8249 or apaluck@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

Short Term Transitional Rehabilitative Care

Recovering from surgery or a major healthcare event can be difficult and often takes more than just a few days. Working together to help you achieve the best possible outcome while providing nursing care and personalized rehabilitation, our goal is to not only get you home safe, but help you stay there. We work with you to focus on recovery, gaining strength and function, as well as education to care for any ongoing conditions.
Our therapy partners – Therapy Solutions – encourages continued recovery and seeks to restore quality and independence to daily living. Using state-of-the-art equipment, our clinical team of nurses, therapists and social workers interact one-on-one with you, to provide a comprehensive program of rehabilitation.
From reliable on-site case management to expert nursing, to innovative rehabilitation techniques, our goal is to maximize functional abilities and have you safely return home at your highest level of independence.

PHONE: Home	Work:	Cell:	Email:

PHONE: Home	Work:	Cell:	Email:

PHONE: Home	Work:	Cell:	Email:

PHONE: Home	Work:	Cell:	Email:

Skilled Care

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

Short Term Transitional Rehabilitative Care

Transitional Service Includes

Contact Us

Height	Current Weight	Usual Weight