Fill and Sign the Rbc Insurance Application Form

Texas State Veterans Homes Application for Admission Jerry Patterson, Chairman For assistance, please contact the Texas Veterans Land Board toll free at 1-800-252-VETS (8387). Last Update 8-01-2012 Texas Veterans Land Board • 1700 N. Congress Ave. • Austin, Texas 78701-1496 Mailing Address • P.O. Box 12873 • Austin, Texas 78711-2873 www.texasveterans.com TEXAS STATE VETERANS HOMES AMARILLO - BIG SPRING - BONHAM - EL PASO - FLORESVILLE - MCALLEN - TEMPLE - TYLER Thank you for making an application to a Texas State Veterans Home. Please attach a copy of the veteran’s discharge document (DD 214 or equivalent). If acting on behalf of the proposed resident, also attach a copy of guardianship documentation or a signed durable medical power of attorney. Mail the application directly to the home of choice. If you have questions as you are completing the application, please contact the home directly, or call the Texas Veterans Land Board at 1-800-252-VETS (8387). Ussery-Roan Texas State Veterans Home 1020 Tascosa Road Amarillo, Texas 79124 Phone: 806-322-8387 Fax: 806-322-8388 Frank M. Tejeda Texas State Veterans Home 200 Veterans Drive Floresville, Texas 78114-2709 Phone: 830-216-9456 Fax: 830-393-7764 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 North Highway 87 Big Spring, Texas 79720-0793 Phone: 432-268-VETS (8387) Fax: 432-268-1987 Alfredo Gonzalez Texas State Veterans Home 301 E. Yuma Avenue McAllen, Texas 78503-1388 Phone: 956-682-4224 Fax: 956-682-4668 Clyde W. Cosper Texas State Veterans Home 1300 Seven Oaks Road Bonham, Texas 75418-3254 Phone: 903-640-VETS (8387) Fax: 903-640-4281 William R. Courtney Texas State Veterans Home 1424 Martin Luther King Jr. Lane Temple, Texas 76504-5941 Phone: 254-791-8280 Fax: 254-791-0262 Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy Street El Paso, Texas 79924 Phone: 915-751-0967 Fax: 915-751-0980 Watkins-Logan Texas State Veterans Home 11466 Honor Lane Tyler, Texas 75708 Phone: 903-617-6150 Fax: 903-617-6498 August 2012 TEXAS STATE VETERANS HOMES AMARILLO - BIG SPRING - BONHAM - EL PASO - FLORESVILLE - MCALLEN - TEMPLE - TYLER APPLICATION FOR ADMISSION Today’s Date _________________________ This application is for placement in the veterans home located in _________________________ Applicant’s Name _____________________________________________________________ Category: Veteran Spouse Surviving Spouse Gold Star Parent PERSONAL INFORMATION How did you hear about Texas State Veterans Homes? ________________________________ Applicant’s Name ______________________________________________________________ Date of Birth ______________________ Current Age _______ Gender: M F VA Claim # _____________________ Social Security Number ______________________ Marital Status _____________________ Spouse’s Name ____________________________ Permanent ____________________________________________________________________ Address (Street) (City) (State) (Zip Code) Email Address ________________________________________________________________ Home Phone _____________________ Other Phone ______________________________ Present Location of Applicant: Home Hospital Nursing Facility Other Current Address (If applicant resides other than at home, please provide the name, address and telephone number of the hospital, nursing facility or other location.) _____________________________________________________________________________ Primary Responsible Party (party who handles applicant’s financial and/or medical affairs) Name __________________________ Relationship ______ Financial ______ Medical______ Address ______________________________________________________________________ Home Phone _____________________ Work Phone _______________________________ Legal Relationship: Self Power of Attorney Legal Guardian Surrogate Decision Maker Secondary Responsible Party (party who handles applicant’s financial and/or medical affairs) Name __________________________ Relationship ______ Financial ______ Medical______ Address ______________________________________________________________________ Home Phone ______________________ Work Phone ______________________________ Legal Relationship: Self January 2012 Power of Attorney Legal Guardian Surrogate Decision Maker TEXAS STATE VETERANS HOMES AMARILLO - BIG SPRING - BONHAM - EL PASO - FLORESVILLE - MCALLEN - TEMPLE - TYLER MEDICAL INFORMATION Primary Physician Address ___________________________________________________________ __________________________________________________________________ __________________________________________________________________ Phone_____________________________ Fax______________________________________ Is your physician willing to come to the Texas State Veterans Home to continue caring for you? Yes No Diagnosis Requiring Long-Term Care (attach copy of medical records or fill out completely) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Other Pertinent Diagnosis ________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Current Medications Name Dosage Frequency ______________________________ __________________ ____________________ ______________________________ __________________ ____________________ ______________________________ __________________ ____________________ ______________________________ __________________ ____________________ ______________________________ __________________ ____________________ ______________________________ __________________ ____________________ (Continue on additional page, if necessary.) Known Allergies _____________________________________________________________ _____________________________________________________________________________ Additional Information __________________________________________________________ _____________________________________________________________________________ January 2012 TEXAS STATE VETERANS HOMES AMARILLO - BIG SPRING - BONHAM - EL PASO - FLORESVILLE - MCALLEN - TEMPLE - TYLER HEALTH INSURANCE INFORMATION Primary Medical Carrier _______________________________________________________________________ Address _____________________________________________________________________ Phone _________________________________ Fax _______________________________ Policy # _________________________________ Group # ____________________________ Name of Policyholder ___________________________________________________________ Secondary Medical Carrier ________________________________________________________________________ Address ______________________________________________________________________ Phone _________________________________ Fax ________________________________ Policy # _________________________________ Group # _____________________________ Name of Policyholder ____________________________________________________________ Dental Insurance Carrier ________________________________________________________________________ Address ______________________________________________________________________ Phone _________________________________ Fax ________________________________ Policy # _________________________________ Group # _____________________________ Name of Policyholder ____________________________________________________________ Other Health Insurance/Long-Term Care Insurance Carrier ________________________________________________________________________ Address ______________________________________________________________________ Phone _________________________________ Fax ________________________________ Policy # _________________________________ Group # _____________________________ Name of Policyholder ____________________________________________________________ January 2012 TEXAS STATE VETERANS HOMES AMARILLO - BIG SPRING - BONHAM - EL PASO - FLORESVILLE - MCALLEN - TEMPLE - TYLER MEDICARE INFORMATION Do you have Medicare Part A? Yes No Do you have Medicare Part B? Yes No Do you have Medicare Part D? Yes No Do you have pharmacy coverage? Yes No Carrier _______________________________________________________________________ Address _____________________________________________________________________ Phone _________________________________ Fax _______________________________ Policy # _________________________________ Group # ____________________________ Name of Policyholder ___________________________________________________________ INCOME INFORMATION Usual Occupation _____________________________ Date Last Employed _________________ Last Employer Name Address Phone If applicant is receiving VA income benefits: Service Connected (SC) Disability Pension $____________per month Service Connected Disability Rating by VA ______________________% Aid and Attendance $____________per month House Bound $____________per month Non-Service Connected (NSC) Pension $____________per month Monthly income before deductions Social Security __________per month Military Retirement $_________per month Private Pension __________per month Workers Compensation $_________per month Other Income __________per month Source _______________________________ __________per month ______________________________________ January 2012 TEXAS STATE VETERANS HOMES AMARILLO - BIG SPRING - BONHAM - EL PASO - FLORESVILLE - MCALLEN - TEMPLE - TYLER If monthly income is not enough to pay applicant’s portion of costs, what other resources are available? (checking, savings, investments, etc.) RATES ARE SUBJECT TO CHANGE AT ANY TIME. _____________________________ _____________________________________ _____________________________ _____________________________________ TEXAS VETERANS SERVICE INFORMATION Branch of Service ____________ Type of Discharge _______________ Date Entered ____________ State/County of Entry _______________ Date Discharged ____________ Discharge Location _______________ Texas Resident Since ____________ Voter Registration County _______________ X Signature of Applicant/Responsible Party Date MAIL THE APPLICATION directly to the home of choice. DO NOT EMAIL THIS APPLICATION due to the Patient Health Information contained in the application. January 2012 TEXAS STATE VETERANS HOMES AMARILLO - BIG SPRING - BONHAM - EL PASO - FLORESVILLE - MCALLEN - TEMPLE - TYLER AUTHORIZATION FOR RELEASE OF INFORMATION Patient’s Name _____________________________________________________ Social Security Number ______________________________________________________ Patient’s Date of Birth _____________________________________________________ AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize and direct any hospital, clinic, medical service facility, medical practice, doctor, insurance company, or other person or institution in possession of any records pertaining to my health, medical condition(s), or medical treatments(s) to release originals or copies of the same to the Texas State Veterans Home, its authorized professional medical service providers, long-term care facilities operators, and/or the medical director for each Texas State Veterans Home. A photocopy or facsimile copy of this authorization/release is as valid as the original. I hereby release, indemnify and hold harmless forever any party who complies in good faith with this authorization from any claim by me, my guardian, my attorney in fact or any other representative, or my estate, based on an assertion of breach of privilege, privacy or other right or duty owed to me. Medical Records to be Released to the Texas State Veterans Home_________________ ___________________________________________________________________________________ Reason for Release__________________________________________________________ Expiration Date of Authorization_______________________________________________ ________________________________________ Signature of Applicant/Responsible Party ___________________________ Date ________________________________________ Signature of Witness ___________________________ Date ________________________________________ Printed Name of Witness ___________________________ Date MAIL THE APPLICATION directly to the home of choice. DO NOT EMAIL THIS APPLICATION due to the Patient Health Information contained in the application. If you have questions, please contact the home or call the Texas Veterans Land Board at 1-800-252-VETS (8387). January 2012