Assisted Living Application | Bethany Retirement Living

ASSISTED LIVING

APPLICATION FOR ADMISSION

Step 1 of 4

25%

PERSONAL INFORMATION

Applicant Name(Required)

First Last

Last 4 Digits of SSN(Required)

Phone Number(Required)

Date of Birth(Required)

Month

Day

Year

Sex(Required)

Female

Male

Email(Required)

First Contact Email

Civil Status(Required)

Religion

RESIDENCY INFORMATION

Current Address(Required)

Street Address City State ZIP Code

How Many Years at this Address?

Please enter a number less than or equal to 100.

Do you rent?(Required)

Yes

Current Landlord (Name or Company)(Required)

Phone Number(Required)

Previous Address

Street Address City State ZIP Code

How many years at this address?

Please enter a number less than or equal to 100.

Did you rent?

Yes

Previous Landlord (Name or Company)

Phone Number

INSURANCE INFORMATION

Complete all applicable sections. Copies of cards may be attached prior or at admission.

Medicare Number

Medical Assistance Number

LTC/Assisted Living Insurance

Company Name

Policy Number

Medicare Prescription Drug Plan

Company Name

Policy Number

Medicare Supplemental Insurance

Company Name

Policy Number

Health Insurance - Other

Company Name

Policy Number

MEDICAL INFORMATION

Primary Physician(Required)

First Last

Clinic Name(Required)

Please list address if not in FM area.

Clinic Phone Number(Required)

Specialty Physician

First Last

Clinic Name

Please list address if not in FM area.

Clinic Phone Number

Pharmacy Name(Required)

Pharmacy Address(Required)

Street Address City State ZIP Code

Dentist

Eye Doctor

Hospital Preference(Required)

Funeral Home Preference(Required)

Funeral Home Address(Required)

Street Address City State ZIP Code

MISC. & BILLING INFORMATION

Are you a veteran?(Required)

Yes

Are you the spouse of a veteran?(Required)

Yes

Do you receive VA benefits?(Required)

Yes

Financial Statements

If you would like your Bethany bill sent to another party such as Power of Attorney, Trust Officer, etc. please list below. If the bill should be sent directly to you simply write “self”.

First Last

Mailing Address

Street Address City State ZIP Code

Relationship

Discard Junk Mail(Required)

Bethany staff will, at your direction, discard mail that does not have first class postage including catalogs and solicitation materials. Identifying information is shredded. Would you like us to assist you?

Yes

Forward Business Mail(Required)

Mail that has 1 st class postage can be forwarded to another party until you are able to make address changes at individual places of business.

Yes

Forward To(Required)

First Name Last Name

Forwarding Address(Required)

Street Address City State ZIP Code

EMERGENCY NOTIFICATION

Please list three people you would want to be contacted in an emergency. List in order of who you would want to be called first. Bethany staff contact only one person. When one person is reached, additional calls are not made by Bethany staff.

Emergency Contacts(Required)

Name

Address

Phone Number

Relationship

ADVANCED DIRECTIVES

Check all that apply Copies required upon admission.

Durable Power of Attorney Finances

Durable Power of Attorney Healthcare

Guardian

Living Will

Code Level

Name of POA or Guardian

First Last

Address of POA or Guardian

Street Address City State / Province / Region ZIP / Postal Code Country

Has the applicant been a resident of Bethany in previous years?(Required)

Yes

About what year?(Required)

Preferred Placement(Required)

Assisted Living

Basic Care

First Available Opening

Future Placement

Short Term / Respite Service

Preferred Location(Required)

Bethany Towers - University Campus

Bethany Gables - 42nd St. Campus

The undersigned represent that all of the above statements are true and complete and hereby authorize Bethany Retirement Living, its employees and agents to contact and obtain information from any individuals or entities that may have information regarding past residential arrangements of the undersigned. The undersigned hereby indemnify and hold harmless American Lutheran Homes, Inc., its employees and agents and all other individuals or entities contacted by American Lutheran Homes, Inc., from all causes of action, expenses, losses or damages of any kind arising from or related to any information obtained regarding the undersigned. All persons will be treated fairly and equally without regard to race, color, religion, sex, familial status, handicap or national origin in compliance with the Fair Housing Act. This application is preliminary only and does not obligate American Lutheran Homes, Inc., to deliver possession or keys to the premises. No contract will be established between the parties until a lease agreement has been signed by all parties. For the safety of our tenants a criminal and credit history will be conducted by Advantage Credit Bureau. Bethany Retirement Living reserves the right to refuse rental to persons with a criminal history. Following the review of credit history and at the discretion of Bethany Retirement Living, a co-signer may be required.

Applicant Signature(Required)

Your Name
Your Name
Your Name

Responsible Party Signature

Your Name
Your Name
Your Name

Bethany Retirement Living Consent for Release of Criminal & Credit Record Search

I hereby authorize Advantage Credit Bureau and Bethany Retirement Living (Bethany Grace Pointe, Bethany Towers, Bethany Gables) or a representative thereof, to examine and copy all records pertaining to any felony and misdemeanor arrests and/or convictions, and to obtain a copy of my individual credit profile report. Copies of said information may be released to Advantage Credit Bureau and Bethany Retirement Living.

Name(Required)

First Last

Last 4 Digits of SSN(Required)

Date of Birth(Required)

Month

Day

Year

Previous Address(Required)

Street Address City State ZIP Code

Please list all states you have resided in:(Required)

Applicant Signature(Required)

Your Name
Your Name
Your Name

Today's Date(Required)

Bethany On University

201 University Drive South

Bethany On 42nd

4255 30th Avenue South

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