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
Supplemental health insurance or Medicare Advantage/PPO/HMO Power of attorney/guardianship papers
Dental Insurance Card
Living will/Healthcare power of attorney
REQUIRED FINANCIAL DOCUMENTATION Both Personal Care and Nursing Care 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 totaling over $500 per month. We will contact you regarding 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 statements. If you are already on Medical Assistance (Medicaid), in another nursing home in PA or on the PA Waiver Program Provide copy of Medicaid approval verification Personal Care – If assets are under $60,000, provide the information below. If above $60,000 follow the guidelines below for nursing care. ___
Statements for all accounts (all Pages) for Past 5 years. This includes checking/savings/credit union/stocks, bonds, IRAs, 401Ks, CDs or other investments
Nursing Care Copies of all pages for all accounts: checking/savings/credit union/stocks, bonds, IRAs, 401Ks, CDs or other investments _
Current 24 month’s statements, plus January & June for 2016, 2017 & 2018. 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
If assets are over $500,000.00 (not including home) for either Personal Care or Nursing Care, please provide:
___
Statements for all accounts (all Pages) for Current 6 months. This includes checking/savings/credit union/stocks, bonds, IRAs, 401Ks, CDs or other investments
NOTE: ANNUAL INVESTMENT STATEMENTS CAN BE SUBSTITUTED FOR MONTHLY STATEMENTS (IF RECEIVED) FOR PAST YEARS. CURRENT STATEMENTS SHOULD BE PROVIDED FOR CURRENT YEAR *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. Medicaid is a financial program thru the State of Pennsylvania. There are separate applications for each program. Page 1
Revised 02/17/2021
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
Page 2
Revised 02/17/2021
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