All Masonic Villages are Non-Smoking
This application will be cancelled 1 year from date of issue if not processed
This application is being submitted for:
Personal Care = Minimal assistance with tasks of daily living, bathing, dressing, medication administration, appointment management (1 hour per day.)
Nursing Care = Moderate to maximum assistance with tasks of daily living
Memory Support/Nursing Care = Moderate to maximum assistance with tasks of daily living, with a memory support area available for those in need at the Elizabethtown and Sewickley facilities.
My desired time frame is (check one):
❑ immediately ❑ in 1 year ❑ in 2 years ❑ in 3 years ❑ longer
Name of Applicant
Masonic/Eastern Star Affiliation
Name of PA Mason/PA Eastern Star Member Initiation Date
Lodge or Chapter Name/#/Location
Failure to complete the application in its entirety or sign below can result in a delay in processing your application
❖ I certify the information contained in this application is correct and complete to the best of my knowledge and the resources listed are and will remain available to pay for all services provided by Masonic Village.
❖ I will not make any transfers or gifts subsequent to the date of this application for residency, including a transfer of assets to an irrevocable trust, or change the liquidity of my assets in any manner, including the purchase of an annuity, which would substantially impair my ability to timely fulfill my financial responsibility and financial obligations to Masonic Village. This provision will be enforced to the extent permitted by applicable law.
❖ I understand that any misrepresentation or willful omission of information on this application will disqualify the applicant for admission and may be cause for discharge if discovered after resident’s admission.
❖ I understand Masonic Village will screen all applicants against the applicable Megan’s Law website.
❖ Financial documentation & Medical Information must be provided as part of the application process
Signature of applicant and/or person completing this application:
Person completing application
Date Decisions concerning admission, the provision of services and referrals of residents are not based on the applicant’s race, color, religion, disability, ancestry, national origin, familial status, age, sex, limited English proficiency (LEP) or any other protected status
FOR OFFICE USE ONLY
Warminster
Masonic Village Application X Elizabethtown Lafayette Hill Sewickley
√ Applicant
√
Date
Application # Date Issued Megan’s Law PC NC Approved: Wait List Denied NC-MS Rehab Stay Hold Signature Date
Full Name Sex M F US Citizen Yes No Date of Birth: Place of Birth Address City State Zip Type of Residence: Own Rent Live with family Personal Care Nursing Care Home Phone # Cell Phone # Email address Previous Address Veteran Yes No or Spouse of Veteran Yes No Branch Former Occupation Retirement Date Religious Affiliation: Marital Status: Single Married Widowed Divorced Separated 1.Full Name of Spouse(living or deceased) 2.Full Name of Spouse(divorced or deceased) Are you registered as: Organ Donor Lions Eye Bank Donor Humanity Gifts Donor Social Security # Medicare # Health Ins ID or Policy # Drug Prescription Ins ID or Policy # Medical Assistance # Do you have Long-term Care Insurance? Yes No If yes, please complete information below: Name of Insurance Co. Agreement/Policy # Effective Date of Coverage Premium Amount $ How often paid? Benefit Period Elimination Period Daily Benefit for Personal Care $ Daily Benefit for Nursing Care $ 1
PERSONAL INFORMATION – APPLICANT #1
POWERS OF ATTORNEY OR GUARDIAN – APPLICANT #1 Name of Financial Power of Attorney/Guardian Address City State Zip Home Phone # Cell Phone # Email address Name of Medical Power of Attorney/Medical Decision Person Address City State Zip Home Phone # Cell Phone # Email address NEXT OF KIN/EMERGENCY CONTACTS – APPLICANT #1 (Medical POA/Decision will be contacted first in event of serious illness or death) 1. Name: Relationship to Applicant Address: Phone: (H) (W) (C) E-mail Address: 2. Name: Relationship to Applicant Address: Phone: (H) (W) (C) E-mail Address: 3. Name: Relationship to Applicant Address: Phone: (H) (W) (C) E-mail Address: FINAL ARRANGEMENTS – APPLICANT #1 Name of Funeral Home Phone # Address Have you prepaid arrangements into an Irrevocable Burial Fund? Amount $ Cemetery 1A
Full Name Sex M F US Citizen Yes No Date of Birth: Place of Birth Address City State Zip Type of Residence: Own Rent Live with family Personal Care Nursing Care Home Phone # Cell Phone # Email address Previous Address Veteran Yes No or Spouse of Veteran Yes No Branch Former Occupation Retirement Date Religious Affiliation: Marital Status: Single Married Divorced Separated 1.Full Name of Spouse(living or deceased) 2. Full Name of Spouse(divorced or deceased) Are you registered as: Organ Donor Lions Eye Bank Donor Humanity Gifts Donor Social Security # Medicare # Health Ins ID or Policy # Drug Prescription Ins ID or Policy # Medical Assistance # Do you have Long-term Care Insurance? Yes No If yes, please complete information below: Name of Insurance Co. Agreement/Policy # Effective Date of Coverage Premium Amount $ How often paid? Benefit Period Elimination Period Daily Benefit for Personal Care $ Daily Benefit for Nursing Care $ 2
PERSONAL INFORMATION – APPLICANT #2
POWERS OF ATTORNEY OR GUARDIAN – APPLICANT #2 Name of Financial Power of Attorney/Guardian Address City State Zip Home Phone # Cell Phone # Email address Name of Medical Power of Attorney/Medical Decision Person Address City State Zip Home Phone # Cell Phone # Email address NEXT OF KIN/EMERGENCY CONTACTS – APPLICANT #2 (Medical POA/Decision will be contacted first in event of serious illness or death) 1. Name: Relationship to Applicant Address: Phone: (H) (W) (C) E-mail Address: 2. Name: Relationship to Applicant Address: Phone: (H) (W) (C) E-mail Address: 3. Name: Relationship to Applicant Address: Phone: (H) (W) (C) E-mail Address: FINAL ARRANGEMENTS – APPLICANT #2 Name of Funeral Home Phone # Address Have you prepaid arrangements into an Irrevocable Burial Fund? Amount $ Cemetery 2A
Check if Applicant 1 Applicant 2 Joint Checking $ $ Savings $ $ Money Mkt $ $ Certificates of Deposit $ $ Investment Acct. $ $ Savings Bonds $ $ IRA, 403B, etc. $ $ Annuities $ $ Trust $ $ Other $ $ REAL ESTATE Property Address #1: Names on Deed: Value: $ Property Address #2: Names on Deed: Value: $ LIFE INSURANCE Applicant 1 Applicant 2 Insurance Co. TypeofPolicy (circle) Group/WholeLife/Term Group/WholeLife/Term FaceValue $ $ CashValue $ $ Premium $ $ Insurance Co. TypeofPolicy (circle) Group/WholeLife/Term Group/WholeLife/Term FaceValue $ $ CashValue $ $ Premium $ $ 3
FINANCIAL INFORMATION ASSETS Please include assets/income of spouse
AUTOMOBILE(S)
MONTHLY INCOME
LIABILITIES
Within the past 5 years, immediately preceding the date of this application, have you or your spouse?
Had a judgment entered against you? Yes No
Paid bills for someone else? Yes No
Declared bankruptcy? Yes No
Transferred/Gifted Assets? Yes No
Opened a Revocable or Irrevocable Family Trust? Yes No
Had money or personal possessions taken without your knowledge? Yes No
Sold your interest in real estate, automobile, other assets? Yes No
If yes, to any of the above, please provide appropriate documentation, judgement, bankruptcy, trust documentation, settlement sheet, etc.
EQUAL HOUSING OPPORTUNITY STATEMENT
The Masonic Village is pledged to the letter and spirit of the U.S. Policy for the achievement of equal housing opportunity throughout the Nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status or national origin.
Applicant 1 Applicant 2 Year & Model Year & Model
Applicant 1 Applicant 2 Social Security $ $ Civil Service $ $ Railroad Retirement $ $ Pension $ $ IRA $ $ Annuity $ $ Other $ $
Applicant 1 Applicant 2 Mortgage Balance $ $ Hm Equity/LOC Balance $ $ Reverse Mortgage Bal. $ $ Rent $ $ Credit Cards $ $
4
Social Security Card
Medicare Card (even if you have an HMO or PPO)
Supplemental Insurance Card
Medicare Advantage Insurance Card
Medical Assistance Card
Drug Prescription Card
Dental Insurance Card
Photo ID, such as driver’s license, State ID, passport or other government issued photo
Financial Power of Attorney or Guardianship Papers
Medical Power of Attorney and/or Living Will
Revocable or Irrevocable Trust Document (all pages) if applicable
Pre-paid Irrevocable Funeral Expenses with funeral home of your choice. Current Lancaster County
Medicaid maximum is $18,564.16
Required Financial Documentation as stated below:
Most recent financial statements for all accounts/investments.
DOCUMENT LIST - APPROVAL
REQUIRED PERSONAL DOCUMENTATION – PLEASE PROVIDE COPIES
