Masonic Village at Elizabethtown Application

Masonic Village at Elizabethtown One Masonic Drive • Elizabethtown, PA 17022-2199 Phone 717-367-1121 • www.masonicvillages.org

A Community of the Masonic Villages of the Grand Lodge of Pennsylvania

Services provided at the following locations: Dallas • Elizabethtown • Lafayette Hill Sewickley • Warminster

To:

Applicant

From:

Jeanie Hummer, Admissions Supervisor

Re:

Application for Admission to Masonic Village for Personal Care or Nursing Care

Thank you for your interest in the Masonic Village at Elizabethtown.

The following items will be needed in order to process your application for admission: 1.

Application for Admission

2.

Documentation for Admission File - items listed on the first page must be returned with the admission application in order for it to be submitted for approval.

3.

Medical Demographics Form – please complete this form and return it with the application for admission.

4.

Physician’s Report – Please provide this form to your family physician for completion. It can be mailed or fax to our office – using the contact information on the 2nd page.

Once your application, documentation, medical demographics and physicians report have been received, we will process your application for approval. We will contact you if further information is needed.

Please do not hesitate to contact our office at 717-367-1121 ext. 33211 or 1-800-422-1207 if you have any questions.

When done, please return the appropriate paperwork to: Masonic Village Admissions Office 1 Masonic Drive Elizabethtown, PA 17022

Masonic Village Application X

Elizabethtown

Lafayette Hill

Sewickley

Warminster

* ALL MASONIC VILLAGES ARE SMOKE FREE * 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, with a memory support area available for those in need at the Elizabethtown and Sewickley facilities.

Rehabilitation Stay – Short-term sub-acute stay with goal to return home.

This application is valid for 1 year from the date of issue and will be canceled if not returned for processing Application #:

Issue Date:

Applicant:

Relationship to Member:

Name of Member: Lodge/Chapter & City: District:

Region:

Initiation Date:

Are you an Eastern Star Member? If yes, Chapter # & City All information has been provided to the best of my knowledge. 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. Failure to complete the application in its entirety or sign below can result in a delay in processing your application.

Signature of applicant and/or person completing this application:

√

√

Applicant

Person completing application

Date

Date Phone

For Office Use

ML: PC

Approved: STR/Wait List

NC

Not approved

Short Stay

Hold

Signature

Date

Masonic Villa 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.

1

PERSONAL INFORMATION Name: Address: Phone #: (H)

(C)

Type of residence:

Rent

Own

__Live w/family - contribute towards expenses? $

Previous Address: Date of birth:

Place of birth:

U. S. Citizen:

Yes

Marital Status:

No Single

Sex: Married

Full Name of Spouse

Male

Separated

Female

Divorced

Wedding Date

Widowed

Date of Divorce

Date of Death

1.

2.

Social Security Number: Do you have: Type of POA:

Medicare Number:

Guardian

Power of Attorney

Financial

Healthcare

Living Will or Healthcare POA

Both

Guardian/Legal Power of Attorney’s Name:

Phone:

Address: Do you have a last will/testament?

Yes

No

Name of Executor:

Are you registered as a donor for the following?

Organ

Yes

No

Do you use Tobacco?

Lions Eye Bank Yes

Yes

No

Humanity Gifts

Retirement Date:

Spouse’s Occupation (former, if retired)

Retirement Date:

Yes

No

No

Occupation (former, if retired) Are you a Veteran?

Yes

No or spouse of Veteran?

Mother’s maiden name:

Yes

No Branch:

Father’s Name:

Religious Affiliation/Congregation:

FUNERAL ARRANGEMENTS Do you have a pre-paid irrevocable burial reserve?

Yes

No

Funeral Home Name & Address: Phone Number:

$

pre-paid

2

NEXT OF KIN/EMERGENCY CONTACTS In case of serious illness, death or billing problems, contact the following in the order provided: (If more room is needed, please use blank sheet at back of application) 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:

FINANCIAL INFORMATION This section must be completed. If married, please include assets/income of spouse ASSETS

APPLICANT

SPOUSE

Checking

$

$

Savings

$

$

Money Market

$

$

Certificates of Deposit

$

$

Securities (stock/bonds)

$

$

Savings Bonds

$

$

IRA

$

$

Annuities

$

$

Trust

$

$

Other

$

$

AUTOMOBILES Please provide Year & Model

APPLICANT

SPOUSE

3

MONTHLY INCOME

APPLICANT

SPOUSE

Social Security

$

$

Pension

$

$

IRA

$

$

Annuities

$

$

Other

$

$

LIABILITIES

APPLICANT

SPOUSE

Mortgage

$

$

Rent

$

$

Home Equity/Line of Credit

$

$

Credit Cards

$

$

Loans

$

$

Other

$

$

Within the past 5 years, immediately preceding the date of this application, have you had a judgment entered against you? _____ Yes _____ No If yes, please provide appropriate documentation

REAL ESTATE Property Location #1: Names on Deed:

Value: $

Property Location #2: Names on Deed:

Value: $

LIFE INSURANCE

APPLICANT

SPOUSE

Policy Owner Name of Ins. Company Whole Life Group or Term Policy paid Up?

Yes

No

Yes

Face Value

$

$

Cash Value

$

$

No

4

GIFTS/TRANSFERS/SALES Within the past 5 years, immediately preceding the date of this application, have you or your spouse: Paid bills for anyone other than yourself from your accounts?

Yes

No

Shared accounts with someone other than your spouse?

Yes

No

Placed assets into a Revocable or Irrevocable Family Trust? (not a funeral/burial trust)

Yes

No

Transferred or gifted your interest in real estate, automobiles, monetary gifts, bank accounts, stocks, bonds, life insurance or other assets?

Yes

No

Sold your interest in real estate, automobiles or other assets for Fair Market Value?

Yes

No

Yes

No

Yes

No

Sold your interest in real estate, automobiles or other assets for less than Fair Market Value?

Had money or personal possessions taken without your permission?

If yes to any of the above questions, please provide explanation and/or documentation If real estate sold, please provide copy of settlement sheet with application

Please use below for additional information or comments

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.

5

HEALTH INSURANCE

If health/prescription drug insurance is thru previous/current employer, please list name of employer:

PLEASE INCLUDE COPIES OF THE INSURANCE CARDS LISTED BELOW WITH THE APPLICATION Primary Medical Insurance: Name as it appears on Insurance Card Agreement/Policy Number Effective Date of Coverage Premium Amount $

Paid How Often?

Secondary Medical Insurance: Agreement/Policy Number Effective Date of Coverage Premium Amount $

Paid How Often?

Drug Prescription Insurance or PACE: Agreement/Policy Number Effective Date of Coverage Premium Amount $

Paid How Often?

Long-term Care Insurance: Agreement/Policy Number Effective Date of Coverage Premium Amount $ Benefit Period Daily Benefit for Personal Care $ Daily Benefit for Nursing Care $

Paid How Often?

Elimination Period

DOCUMENTATION FOR APPROVAL

Please return the items below with your application in order for it to be reviewed.

Copies of front/back of the following cards: Social Security

Medicare Card

Drug prescription Card

Dental Insurance Card

Supplemental health insurance or Medicare Advantage/PPO/HMO

We do not participate in HMO’s. If this is your coverage, we will ask you to change it prior to admission.

To obtain a Social Security/Medicare Card, contact your local Social Security Office/obtain an application: www.ssa.gov Power of attorney/guardianship papers Living will/Healthcare power of attorney FINANCIAL DOCUMENTATION Applications are reviewed under Medicaid guidelines which has a 5 year look-back period. Checks written in amounts over $500 are questioned, as well as any checks written in even numbered amounts which total over $500 per month.

We will contact you regarding any checks which meet the criteria to gain information before the application is submitted for review. If available, please provide check copies or a check register with the statements below.

If you are already on Medical Assistance (Medicaid) , in another nursing home or on the PA Waiver Program – please provide a copy of your approval verification.

If you are not on Medical Assistance (Medicaid) provide: Assets between $0 to $300,000 (not including home) please provide: Copies of all pages for all accounts: checking/savings/credit union/stocks, bonds, IRAs, 401Ks, CDs or other investments Past 24 months, plus January & June of 2014, 2015 & 2016 Assets between $301,000 to $499,000 (not including home) please provide: Copies of all pages for all accounts: checking/savings/credit union/stocks, bonds, IRAs, 401Ks, CDs or other investments Past 24 months, plus January & June of 2015 & 2016 Assets $500,000+ (not including home) please provide: Copies of all pages for all accounts: checking/savings/credit union/stocks, bonds, IRAs, 401Ks, CDs or other investments Past 6 months Verification of any accounts or resources closed or cashed in during the past 5 years and proof of where the Funds were deposited or spent Copy of all pages of Revocable or Irrevocable Family Trust, if applicable Real Estate – Deed for property owned and/or title of mobile home OR settlement sheet if you have sold or transferred property within the past 5 years Reverse Mortgage – provide documentation which includes payoff amount Registration for motor vehicles Bankruptcy Documentation, if applicable Page 1 Revised 09/12/17

The items below must be provided to the Admissions Office prior to or at the time of admission.

Items checked off have been received. Provide a new copy if a change has occurred.

Photo ID- Driver’s, State ID or other government issued photo Birth or baptismal certificate Citizenship or Naturalization papers, if applicable Marriage Certificate if married and spouse is living Proof of death of spouse, if applicable (death certificate, obituary, remembrance card, or letter from funeral hm) Divorce Decree, if applicable Honorable Discharge from Service, if applicable Social Security Award Letter (issued in December) Verification of gross income for pensions, annuities, IRA and any other income. (Note: Bank statements are not acceptable verifications, 1099’s or income statements that show gross amount are acceptable) Proof of Face & Current cash surrender value of all life insurance policies, if there is no cash value then provide documentation verifying the policy is a term life or group life. Note: If you will be a Fraternal Care* or Medicaid resident, the Masonic Village will not cover life insurance premiums, all income must be used towards cost of care.

Irrevocable burial reserve or pre-arranged/pre-paid funeral arrangement - Please pre-arrange/pre-pay funeral expenses with a funeral home of choice. This contract must be irrevocable. It will provide assurance funds will be available for expenses when needed. If you plan on using paid up life insurance policy(s) for your costs, we recommend you talk with your funeral director regarding your policy(s) to arrange for them to be assigned to the funeral home, making sure the arrangement is irrevocable. If funds will be available upon the sale of real estate or other assets, it is recommended that an irrevocable contract be done. The current irrevocable funeral reserve Medicaid maximum allowable in Lancaster County is $14,375.00.

All pages of income tax returns for last 5 years or 1099’s if did not file

*Fraternal Care is financial program thru the Masonic Village which will step in to assist when assets deplete and you are a personal care resident. There will be a separate application to complete for this program.

Page 2

Revised 09/12/17

MASONIC VILLAGE MEDICAL DEMOGRAPHICS FORM Date:

Name of Applicant: PHYSICIAN INFORMATION

Name of family physician

Phone #

Specialists seen in the last 5 years: Physician

Phone #

Reason Physician

Phone #

Reason: Physician

Phone #

Reason HOSPITALIZATIONS Hospitalizations within the past 5 years: Hospital

Phone #

Reason

Date Admitted

Hospital

Date Discharged Phone #

Reason

Date Admitted

Hospital

Date Discharged Phone #

Reason

Date Admitted

Date Discharged

PSYCHIATRIC OR MENTAL HEALTH TREATMENTS Past psychiatric or mental health treatments: Physician or hospital name & address Diagnosis

Date Admitted

Date Discharged

Date Admitted

Date Discharged

Physician or hospital name & address Diagnosis

OTHER FACILITIES Have you resided in a nursing home, personal care or assisted living facility in the past 5 years?

Name & address of facility Reason

Phone: Date Admitted

Name & address of facility Reason

Date Discharged Phone:

Date Admitted

Date Discharged

Yes

No

Name of Applicant: SPECIAL TREATMENTS Check all that apply & indicate dates of service Chemotherapy

Date

Oxygen

Date

Radiation

Date

Dialysis

Date

Feeding Tube

Date

C-pap

Date

Wound Care

Date

Bi-pap

Date

ACTIVITIES OF DAILY LIVING NEEDS Do you need assistance with your medications?

Yes

No

Do you need any assistance with your activities of daily living?

Yes

If yes, what type of assistance is needed?

No

If yes, please use the key below and check off type of assistance needed: I = Independent (no help or supervision needed)

Bathing/Showering

I

S

L

E

T

S = Supervision (encouragement or cueing needed)

Dressing/Undressing

I

S

L

E

T

L = Limited (some light physical help needed)

Grooming/Hygiene

I

S

L

E

T

E = Extensive (physical help needed, can do some self-care)

Eating/Drinking

I

S

L

E

T

T = Total Assistance (full physical help needed)

Transferring out of bed or chair

I

S

L

E

T

Toileting

I

S

L

E

T

Continence of bladder & bowel: Continent, complete control Usually continent, incontinence once a week or less Occasionally incontinent, approximately 2 times per week, but not daily Frequently incontinent, incontinent daily, but some control present Incontinent, no control, multiple episodes If incontinent, do you handle yourself?

Yes

MOBILITY

Do you use any of the following?

Cane

Walker

Scooter

What distance are you comfortable walking?

Can you do steps?

No

Wheelchair

Electric Wheelchair

Prosthesis/brace

Name of Applicant: COGNITIVE FUNCTIONING Orientation: Time

No Problem

Sometimes a problem

Often a problem

Place

No Problem

Sometimes a problem

Often a problem

Person

No Problem

Sometimes a problem

Often a problem

Recent memory

No Problem

Sometimes a problem

Often a problem

Distant memory

No Problem

Sometimes a problem

Often a problem

Able to take direction

No Problem

Sometimes a problem

Often a problem

Wandering behavior

No Problem

Sometimes a problem

Often a problem

Verbally abusive

No Problem

Sometimes a problem

Often a problem

Physically abusive

No Problem

Sometimes a problem

Often a problem

Inappropriate/disruptive behavior, ex. yelling out

No Problem

Sometimes a problem

Often a problem

DIETARY NEEDS Do you follow any dietary restrictions?

Vegetarian

Low Carbohydrate

Paleo

Gluten Free

Religious-based

Other: Have you been diagnosed with an allergy to any foods?

Wheat

Soy

Eggs

Other:

Comments:

Shellfish

Finfish

Milk

Tree Nuts

Peanuts

Physicians Report I, am in the process of applying for admission to the Masonic Village at Elizabethtown, Pennsylvania. This form will assist the Masonic Village staff in identifying the most appropriate level of care for me. By my signature below, I am authorizing you to release the following information to the Masonic Village: x

Signature

Date of Birth

Date

*Physician to complete sections below* What type of facility is most appropriate for this applicant: Personal Care – some assistance with activities of daily living Nursing Care – 24 hour nursing care in health care center Dementia Care – Secure 24 hour nursing care in health care center HEIGHT:

WEIGHT: DIAGNOSIS

MEDICATION

Drug Allergies:

Page 1 of 2

HOW PRESCRIBED

IMMUNIZATIONS: PPD Date Influenza Vaccine Date Pneumonia Vaccine Date Tetanus Date

Reaction Reaction Reaction Reaction

Past Medical History:

Surgery History:

Medical Treatments:

Hospitalizations (past 5 years):

Mental Health Treatments:

Please attach a copy of the past 6 months medical records to this form, including any lab reports such as: CBC CMP

Electrolytes Urinalysis

EKG Chest X-ray

Previous Mammogram

Physician’s Signature:

Date:

Complete below or attach a business card: Address: Office Phone #

Fax #:

If an envelope is not attached, please fax or forward this report to: Masonic Village at Elizabethtown Admissions Office One Masonic Drive Elizabethtown, PA 17022-2199 Office # 1-800-422-1207/Fax # 717-361-5500