Application For Residency

Applicant's Financial Information

All residents will need to be financially approved prior to admission. Tennyson Court will require copies of bank/account statements and tax returns.
Monthly Income
Social Security
Pension
Veterans Pension
Other
Total Monthly Income (auto calculated)
Assets
Checking Account(s)
Savings Accounts(s)
CD's
401k/IRA
Other
Total Assets (auto calculated)
Real Estate
Do you own any real estate?*

YesNo
If Yes,
Do you have any Liens or Debt?*

YesNo
If Yes,
Do you have Long-Term Insurance?*

YesNo
If Yes,

Applicant's Health Information

Tennyson court will be required to screen the applicant prior to admission to confirm applicant is appropriate for our community. Tennyson reserves the right to accept or decline resident based on this screen.
Primary Care Physician's Information*
Other Physicians
Preferred Hospital (provide two options)*
Insurance Information

Copies of Insurance cards must be received prior to admission. You can upload them now, e-mail them or provide them in person at a later date.
Medicare #*
Medicare Type*

Part APart B
Upload Copy of Medicare Card

If your file is too large to upload - please email to the Admissions Director or bring to your next appointment. File size limit 1MB
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Additional Insurance/Prescription Plan
Upload Copies of Additional Insurance Cards/Information

If your file is too large to upload - please email to the Admissions Director or bring to your next appointment. File size limit 1MB
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Additional Information
Does the Applicant Have Any of the Following?:
Power of Attorney*

YesNo
Health Care Proxy*

YesNo
Living Will*

YesNo
Advance Directives*

YesNo
If Yes,

Copies of these documents must be recieved prior to admission. You can upload them now, e-mail them or provide them in person at a later date.
Upload legal documents

If your file is too large to upload - please email to the Admissions Director or bring to your next appointment. File size limit 1MB
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Burial Instructions/Funeral Home *

Additional Services

If ye to any of the below questions, more information will be provided through the admission process.
Tennyson Court provides Retirement Home TV (Dish) at no charge.
Tennyson Court offers phone service for $50 additional per month?*

Yes, I will require a landlineNo
Incontinence Products are available through Tennyson Court for an additional charge. Would you like to learn more about this program?*

YesNo
Would you like to learn more about the dental services offered on-site by At Home Dental of WNY?*

YesNo

Pharmacy Agreement
Tennyson Court Senior Care community offers the delivery services of Buffalo Pharmacies to our residents:
Will Applicant be utilizing Buffalo Pharmacy services?*

Yes, I would like to use Buffalo Pharmacies. I understand that all prescriptions must be provided to Tennyson Court.No, I plan to remain with my current outside pharmacy and agree to take responsibility for all re-fills needed and any prescription changes that may be ordered from your PCP.
Current pharmacy*
If yes, please confirm contact/address for Buffalo Pharmacies Billing:
Co-pays and non-covered services are the responsibility of the resident/families.
Applicant's Signature:

Clear
Applicant's Representative Signature:*

Clear
Tennyson Court Representative's Signature _______________________________

Date ________________

Podiatry Agreement
Tennyson Court Senior Care Community is pleased to offer podiatry services on site to our residents.
Would applicant like receive podiatry care?*

Yes, we would like on-site podiatry services.No, we will use off-site podiatrist as needed.
Tennyson Court is not responsible for the billing from the Podiatrist, If you have any questions, please contact us for the name and number of the Podiatrist servicing you or your loved one.

Co-pays and non-covered services are the responsibility of the resident/families.
Applicant's Signature:

Clear
Applicant's Representative Signature:*

Clear
Tennyson Court Representative's Signature _______________________________

Date ________________

Primary Care Provider
Tennyson Court Senior Care Community is pleased to offer a partnershup with Partners Medical, LLP to provide on-site primary care services to our residents.

Would applicant like to change primary care providers and to recieve services through Partners Medical, LLP? These providers are not employees of Tennyson Court, and their decisons and operations are seperate from our orgnaization.
Please indicate below:*

Yes, we would like to switch primary care providers to Partners Medical, LLP.No, we will use our off-site primary care provider.
Tennyson Court is not responsible for the billing from Partners Medical, LLP, If you have any questions, please contact us for the name and number of the provder servicing you or your loved one.

Co-pays and non-covered services are the responsibility of the resident/families.
Applicant's Signature:

Clear
Applicant's Representative Signature:*

Clear
Tennyson Court Representative's Signature _______________________________

Date ________________

I hereby certify that the information I have supplied is correct and complete to the best of my knowledge. I understand that any misrepresentation could result in the forfeiture of my status as a resident of Tennyson Court Assisted Living and Memory Care.
Applicant's Signature

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Name of Applicant's Representative completing this form:*

First NameLast Name
Applicant's Representative's Signature *

Clear
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Emergency Contact Information