Before You Begin

Thank you for your interest in Lutheran Care Center, a 160-bed skilled nursing facility owned and operated by The Lutheran Care Network, a non-sectarian, non-profit organization dedicated to serving the needs of the community.

To be considered for admission, please complete this application. In addition, we need:

A PRI (Patient Review Instrument) and screen, completed by a qualified nurse and forwarded to us.
Copies of all financial records — bank statements, pension and Social Security amounts, investments, assets, etc. We use these to determine whether an application for Medicaid is necessary.
Copies of insurance cards so we can verify coverage.
Copies of the Power of Attorney, Guardianship, Trust, Social Security card, Medicare card, Medicaid card, Long Term Care Insurance policy, and prescription drug card, as applicable. All copies must be submitted in paper.

After we receive these documents, we will review the information and determine whether the applicant is appropriate for the services we provide.

For more information or to arrange a personal tour, contact the Admissions Department at 845-486-9494, ext. 234. Documents can be faxed to 845-486-9498.

It is our policy to prohibit discrimination on the basis of race, creed, color, national origin, handicap, blindness, sex, age, source of payment, marital status, sexual preference, sponsorship or any other legally protected status in the admission, retention and care of residents.

Relatives / Significant Others to Be Contacted

List in order of responsibility.

Contact 1

Name

Relationship

Address

Home Telephone

Cell Phone

Email Address

Has Power of Attorney? Yes No

Has Health Care Proxy (HCP)? Yes No

Contact 2

Name

Relationship

Address

Home Telephone

Cell Phone

Email Address

Has Power of Attorney? Yes No

Has Health Care Proxy (HCP)? Yes No

Financial Disclosure

Monthly Income

Source	Applicant	Spouse	Where Sent or Deposited?
Social Security
Pension
Dividends/Interest
Annuities
Other Income

Checking Account

Name & Address of Bank

Account #

Name(s) on Account

Balance

On Date

Comments (if needed)

Savings Accounts, Certificates of Deposit, Money Market Funds, Stocks

Account 1

Name & Address of Bank

Account #

Name(s) on Account

Balance

On Date

Account 2

Name & Address of Bank

Account #

Name(s) on Account

Balance

On Date

Annuity / 401K / IRA

Institution / Description

Account #

Name(s) on Account

Balance

On Date

Other Assets

Trusts Yes No

Type of Trust

Any other financial asset information not noted above

Life Insurance – Company

Policy #

Beneficiary

Does the applicant own their home? No Yes

Value

Name(s) on Deed

Does the applicant own other real estate or property? No Yes

Description

Value

Name(s) on Deed

Has there been any transfer of assets (funds, property or real estate) within the past 60 months? Yes No

Amount and explanation

Applicant's Attorney Name

Attorney Phone

If funeral arrangements have been made, provide the name, address, and phone number of the funeral home

Please provide copies of the Power of Attorney, Guardianship, Trust, recent bank statements, Social Security card, Medicare card, Medicaid card, other insurance cards, Long Term Care Insurance Policy, and prescription drug card. All copies must be submitted in paper.

I certify that the information provided is true and accurate.

Signature (type full name)

Date

Signed by Applicant Responsible Person

Print Name

Admission Application

Before You Begin

Applicant Information

Relatives / Significant Others to Be Contacted

Current Medical Insurance Information

Financial Disclosure

Monthly Income

Savings Accounts, Certificates of Deposit, Money Market Funds, Stocks

Other Assets

Medical Data

Nursing Needs

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Lutheran Care Center