VCLC at Fitzsimons admission form

Medical and health insurance information
Applicant's Social Security Number*
Applicant's Medicare number*
Does applicant have Medicare Part A?*

YesNo
Does applicant have Medicare Part B?*

YesNo
Secondary/supplemental insurance
Insurance ID number
Medicare Part D or other Rx coverage
Insurance ID number
Does applicant have Medicaid?*

YesNo
If yes, provide Medicaid number
Has applicant received medical care from the VA?*

YesNo
If yes, please indicate where, when and what the applicant received treatment for
If yes, please provide the VA claim number

Financial information

The following financial information is required to determine eligibility for benefits and ability to pay. Please state gross monthly amounts before any deductions.
Monthly income
Social Security (applicant)
Social Security (spouse)
Civil Service (applicant)
Civil Service (spouse)
Railroad retirement (applicant)
Railroad retirement (spouse)
Non-VA military retirement (applicant)
Non-VA military retirement (spouse)
VA service-connected disability compensation (applicant)
VA service-connected disability compensation (spouse)
VA pension (applicant)
VA pension (spouse)
Other pensions (applicant)
Please specify which pension(s)
Other pensions (spouse)
Please specify which pension(s)
Gross employment wages (applicant)
Gross employment wages (spouse)
Total monthly income (applicant)
Please add all of the amounts above
Total monthly income (spouse)
Please add all of the amounts above
Assets
Cash/checking account/savings (applicant)
Cash/checking account/savings (spouse)
Investments (applicant)
Investments (spouse)
Trusts (applicant)
Trusts (spouse)
Real estate, other than your residence (applicant)
Real estate, other than your residence (spouse)
Other (applicant)
Other (spouse)
Financial affairs
If you are admitted to the Veterans Community Living Center at Fitzsimons, who will handle your financial affairs?

First NameLast Name
Phone number
Please enter a valid phone number.

Documents

Please upload copies of the following documents.
Military separation orders or discharge papers (DD214 or similar document)

Cancelof
Service-Connected Disability Award Letter from the VA, if applicable

Cancelof
Front and back of all insurance cards

Cancelof
Medical POA, General POA, guardian/conservatorship documents and living will, if available

Cancelof

Signature

Please read the statement below and click "I agree" to sign. The applicant or their power of attorney may sign and submit this form.
I understand that it may be necessary for me to provide copies of bank statements periodically to verify my financial position, and that I must keep my account current. If I am admitted, I agree to abide by the rules and regulations of the Veterans Community Living Center at Fitzsimons. I realize that the facility is operated in full compliance with the Civil Rights Act of 1964, and the Americans With Disabilities Act of 1990, and that I am to cooperate with the nursing home in maintaining full compliance. I authorize the Veterans Community Living Center at Fitzsimons to verify any and all information provided on this form. The information I have provided is true and complete to the best of my knowledge and belief.*

I agree
Name person submitting this form*

First NameLast Name
Should be Empty:

Veterans Community Living Center at Fitzsimons admission form