Fill and Sign the Health Insurance Application for Extended Family Planning Benefits Form

1600 Veterans Drive/PO Box 673 Lisbon, ND, 58054-0673 Admissions: (701) 683-6540 Fax (701) 683-6550 APPLICATION FOR ADMISSION NORTH DAKOTA VETERANS HOME SFN 60100 (1-2012) APPLICANT/RESIDENT INFORMATION Type of Care (check one) Name Basic Care Unit Skilled Unit (Nursing Home) AKA, Maiden Name, Former Name Telephone Number County Address City State Birth Place Social Security Number Date of Birth Gender Male Age ZIP Code Female In compliance with the Federal Privacy Act of 1974, the disclosure of the social security number on this form is voluntary. They are not disclosed to the public, the individuals social security number is used for identification purposes and to determine eligibility for residency at the North Dakota Veterans Home pursuant to Administrative Code 86-13-01-02. While voluntary disclosure is requested; failure to do so will prevent this application from being processed. Marital Status Religion Single Mother's Maiden Name Married Separated Divorced Widowed Race White American Indian Black or African American Yes Are you under Guardianship? Asian Other (specify): No Name of Guardian Telephone Number Address City Do you have a current Drivers License? Driver's License Number Yes No Do you have a police or criminal record? Yes Yes No Expiration Date ZIP Code Vehicle License Number No Have you been convicted of a felony? State If yes, briefly describe: Where have you lived in the past two years? (City, County, State) List the states in which you lived in other than North Dakota (also indicate the years) Have you been a member of the ND Veterans Home? Yes No Reason for Leaving Previous Occupation Last Date of Employment Current Living Arrangements House Apartment Other (specify): Primary Physician Physician Telephone Number Date Last Seen by Physician INSURANCE INFORMATION: please provide a copy of all current insurance cards Are you eligible for Medicare? Yes No Medicare Number Part A Effective Date Part B Effective Date Are you eligible for Medicaid? Yes No Medicaid Number Do you have any other health insurance? Yes Part D Effective Date No If yes, please list including the name and address of insurance company Name of Insurance Company Address Policy Number City State ZIP Code SFN 60100 (1-2012) Page 2 of 5 VA/MILITARY INFORMATION Service in the Armed Forces Please check WWII Self Korean Type of Discharge Spouse * If you are the spouse provide veteran information. Viet Nam Lebanon Service Branch of Service Dates of Service From: To: Panama Service Persian Gulf Rank Serial Number Claim Number Do you have a VA service connected rating? Yes No Peacetime Last Entry Date Service Organization with POA If yes, what percentage? Condition YES Are you a Purple Heart recipient? Are you a former Prisoner of War? Are you receiving Aid & Attendance from the VA? Are you considered Homebound? Did you serve in combat after 11/11/1998? Was your discharge from the military for a disability incurred or aggravated in the Line of Duty? Are you receiving disability retirement pay instead of VA compensation? Were you exposed to Agent Orange while serving in Vietnam? Were you exposed to radiation while in the military? Did you receive nose and throat radium treatments while in the service? Do you have a spinal cord injury? Do you use the Fargo VA system for medical care? Do you pay co-pays for medications at the VA? LEGAL DOCUMENTATION Check the following documents you have. These documents must be sent with the application. Certified Copy of Honorable Military Discharge (DD-214) Widow(er) needs to submit veteran’s death certificate Completed 10-10SH as well as a chest x-ray completed in the last six months Durable Power of Attorney Durable Medical Power of Attorney Guardianship Conservator Award letter from Veterans Affairs- verifying pension/compensation Copy of current Driver's License Copy of last bank statement, IRA’s etc. Verification of income and assets Copies of insurance cards, including Medicare and secondary insurance if applicable Copy of current vehicle insurance if applicable Copy of Social Security card Signed authorization for background check Signed medical releases of information NO SFN 60100 (1-2012) Page 3 of 5 FAMILY MEMBERS Name of Spouse Living Address Telephone Number Deceased - Date: City State ZIP Code Children (if more, list on back of form) Name of Child Address Telephone Number City Name of Child Address City State ZIP Code Telephone Number City Name of Child Address ZIP Code Telephone Number Name of Child Address State State ZIP Code Telephone Number City State ZIP Code EMERGENCY CONTACT (in case of emergency, notify): Name Home Telephone Number Relationship Business Telephone Number Address City State ZIP Code Name Home Telephone Number Relationship Business Telephone Number Address City State ZIP Code FINANCIALLY RESPONSIBLE PARTY Name Home Telephone Number Relationship Business Telephone Number Address City State ZIP Code Send Statement/Bill To: Name Address Telephone Number City State ZIP Code SFN 60100 (1-2012) Page 4 of 5 INCOME Monthly Annual ALLOWABLE EXPENSES VA Pension Hospital Insurance Social Security Medicare RR Retirement Farm Taxes Farm Income Glasses Interest Dental Other Annual Medicine VA Compensation Monthly Hospitalization Doctor Bills Court Ordered Child Support TOTAL TOTAL TYPE OF ASSETS (provide verification) Checking Account Name of Bank Savings Account/CD, IRA Accounts Amount Name of Bank Address City Amount Address State ZIP Code City State ZIP Code Amount Automobile Real Estate - Describe: Other Property - Describe: HOSPITALIZATION Have you been hospitalized in the last 12 months? Yes No If yes, complete the following information: Acute Hospital Name: (most recent) Admit Date Discharge Date Skilled Nursing Facility Name: (most recent) Admit Date Discharge Date Applicant/Resident is Currently Residing at Admit Date CURRENT PHYSICAL HEALTH PROBLEMS Alzheimer’s, Dementia Hallucinations Parkinson’s Cancer Decubitus Ulcer Fracture Contractures Heart Disease Hypertension CVA/Stroke Paralysis Speech Impaired Insomnia Arthritis Pain; Location Seizure Disorder Heart Disease Bowel Incontinence Urine Incontinence Catheter Use Diabetes Obesity Infections (UTI, Respiratory, etc.) Respiratory; Using O2 @ __________ Liters Alcohol Consumption Smoker Allergies - List: Kidney Disease Comments Others SFN 60100 (1-2012) Page 5 of 5 Which of the Following Best Describes the Applicants Ability to Walk: Fully independent Uses wheel chair independently Uses gait belt Unsteady Uses wheel chair with assistance Total assistance with transfers Scooter Uses cane or walker with assistance Falls History? Yes No Most Recent Fall Date How many falls in last month? Comments Any other information that you feel may be important: Signature Date Witness Date CERTIFICATION OF RESIDENCY This is to certify that applicant has been a resident of North Dakota for 30 days prior to date of this application. Signature Date Printed Name ALL SERVICES AND BENEFITS ARE PROVIDED BY THE HOME ON A NON-DISCRIMINATORY BASIS AS REQUIRED BY THE CIVIL RIGHTS ACT AND REGULATIONS OF THE VETERANS ADMINISTRATION ON THE GROUNDS OF RACE, COLOR, OR NATIONAL ORGIN.