Submit Residency Application
I am applying for a residency at:
*
Please Select
NEHD's Rest Home
NEHD's Skilled Nursing Community
Step 1: Personal Information
Personal Information
Full Name
*
First Name
Last Name
Email
*
example@example.com
Video Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Demographics (Optional)
Citizenship
U.S.
Canadian
Other
Marital Status
Never Married
Married
Widowed
Divorced
Ethnicity
White
Black/African American
Hispanic/Latino
Other
Religion
Education
Occupation
Step 2: Health-related Information
Health-related Information
Medicaid / MassHealth ID
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Medicare Beneficiary ID
*
Other medical insurance
LTC insurance
I'll provide a copy of the following document(s). Check each that applies.
*
Birth Certificate
Medicaid / MassHealth ID
Medicare Beneficiary ID
Other medical insurance ID
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*
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of
List of current medications
*
Summary of medical history
*
A history and physical examination performed within the last 90 days, including current medication list, must be submitted for review by the clinical director.
I will provide medical history documents.
*
Yes
No, I will submit at a later time. I acknowledge that my application will not be proccessed without this information.
Medical History Documents
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Please note that documentation of medical history and a physical completed within the last 90 days are required to process your application.
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Has anyone been designated as:
Power of Attorney
Guardian
Healthcare Proxy
If so, please specify name, address, phone, and email.
Enter Name, address, phone, and email.
POA / HCP / Guardianship Documents
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Step 3: Financial Information
Financial Information
Total Monthly Income
*
Social Security, SSI, Veterans Benefits, Pension / Annuity, Other
I'll provide a copy of the following document(s) as a proof of income.
*
Social Security
SSI
Veterans Benefits
Pension / Annuity
Other
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*
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of
Total Assets
Residence (own), Other Real Estate including Property Sold/Transferred Within Last 5 Years
I'll provide a copy of the following document(s).
Residence Property Tax Bill
Other Real Estate Property Tax Bill
Closing Statement for Property Sold/Transferred Within Last 5 Years
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of
Total Bank Accounts
*
Checking, Savings, Certificates of Deposit
I'll provide a copy of the following document(s).
*
Checking (bank statements, last 5 years)
Savings (bank statements, last 5 years)
Certificates of Deposit (bank statements, last 5 years)
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*
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of
Total Investments
Stocks, Bonds, Life Insurance, Prepaid Burial Account
I'll provide a copy of the following document(s).
Stocks / Bonds (statements, last 5 years)
Life Insurance (current statement)
Prepaid Burial Account (contract)
N/A
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of
Consent
*
Yes, I understand that in order to process my application, NEHD needs to verify a source of payment for the stay at their facility.
I understand that incomplete or inaccurate information will delay processing of my application.
Yes, I give my consent to verify any information given herein.
Signature
*
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