Eligibility for Admissions Application
Find out if you or your loved one is eligible for admission into our services. Please contact us if you have any questions 607-898-5876 and ask for someone in the Admissions Department.
Name of Person Seeking Eligibility
*
Mr.
Dr.
Mrs.
Ms.
Miss
Prefix
First Name
Middle Name
Last Name
Date of Birth of Person Seeking Eligibility
*
-
Month
-
Day
Year
Date
Sex of Person Seeking Eligibility
*
Male
Female
Phone Number of Person Seeking Eligibility
Please enter a valid phone number.
Email of Person Seeking Eligibility
example@example.com
Person to Contact Regarding this Application
*
First Name
Last Name
Email of Person to Contact
*
Please use a valid email. A confirmation email regarding this application will be sent to THIS email.
Phone Number of Person to Contact
*
Please enter a valid phone number for a staff member to call if questions regarding this application arise.
Relationship to Person Seeking Eligibility
*
Self (I am the applicant)
Spouse
Child of Person Seeking Eligibility
In-Law of Person Seeking Eligibility
Other
Please answer all the questions as completely and accurately as possible. This information is important for admissions to Groton Community Health Care Center.
All answers will be held in the strictest confidence.
Social Security Number of Person Seeking Eligibility
*
Enter SSN
Marital Status of Person Seeking Eligibility
Religious Preference of Person Seeking Eligibility
Current Address of Person Seeking Eligibility
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Address
Home
Adult Home
Nursing Home
Hospital
Other
Reason for Admission Request
Physician Name for Person Seeking Eligibility
Hospital Preference
Guthrie Cortland Medical Center
Cayuga Medical Center
Other
If OTHER for Hospital Preference, please enter name of hospital below
Source of Payment for Services
Check payment option that applies to applicant.
Private Payment?
Yes, Party will Private Pay.
No, Party will NOT Private Pay.
If YES, the responsible party indicates adequate funds to pay for the applicant's care for a period of time. This in no way infringes upon the applicant's right to apply and/or become eligible for third party payment
How many months will party private pay?
Medicaid
Recipient's Medicaid Identification Number
County
Other Long-Term Care Insurance
Name of Insurance Coverage
Recipient's Policy Number
Insurance Company's Phone Number
Please enter the phone number on the back of the card.
Does person seeking eligibility have a Medicare Advantage Plan?
Yes
No
Plan Type
Medicare Beneficiary Identifier Number
Medicare Number Found on Card
Does Recipient Have Medicare Part A?
Yes
No
Does Recipient Have Medicare Part B?
Yes
No
Does Recipient Have Medicare Part D?
Yes
No
Prescription Drug Plan
Prescription Drug Plan ID Number
Name of Additional Insurance Company
Identification Number of Additional Insurance Company
Policy Number of Additional Insurance Company
Phone Number of Additional Insurance Company
Please enter the phone number on the back of the card.
Responsible Party for Payment
Power of Attorney/Person Handling Applicant's Finances
Name of Responsible Party for Payment
First Name
Middle Name
Last Name
Address of Responsible Party for Payment
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please indicate the amount of income you receive from each of the following sources and the frequency of income received (weekly, monthly, quarterly, annually).
Source of Income:
Social Security Amount
Enter Amount Received
Social Security - Frequency Income Received
Please Select
Weekly
Monthly
Quarterly
Annually
Enter Frequency
Supplemental Security Amount
Enter Amount Received
Supplemental Security - Frequency Income Received
Please Select
Weekly
Monthly
Quarterly
Annually
Enter Frequency
Interest Income
Enter Amount Received
Interest Income - Frequency Income Received
Please Select
Weekly
Monthly
Quarterly
Annually
Enter Frequency
Dividend Income
Enter Amount Received
Dividend Income - Frequency Income Received
Please Select
Weekly
Monthly
Quarterly
Annually
Other
Enter Frequency
Pension Income
Enter Amount Received
Pension Income - Frequency Income Received
Please Select
Weekly
Monthly
Quarterly
Annually
Other
Enter Frequency
Annuity Income
Enter Amount Received
Annuity Income - Frequency Income Received
Please Select
Weekly
Monthly
Quarterly
Annually
Other
Enter Frequency
Other Income
Enter Amount Received
Other Income - Frequency Income Received
Please Select
Weekly
Monthly
Quarterly
Annually
Other
Enter Frequency
Please indicate below the approximate market value of each of the following assets you own
Assets
Cash Checking Account - Value in Dollars
Enter Amount
Cash Savings Account - Value in Dollars
Enter Amount
Certificate of Deposit - Value in Dollars
Enter Amount
Retirement Funds (IRA/401k/403b) - Value in Dollars
Enter Amount
Securities: Stocks/Bonds/Mutual Funds - Value in Dollars
Enter Amount
Notes and Contracts Receivable - Value in Dollars
Enter Amount
Life Insurance (Cash Surrender Value) - Value in Dollars
Enter Amount
Personal Property - Value in Dollars
Enter Amount
Real Estate (Market Value) - Value in Dollars
Enter Amount
Other Assets - Value in Dollars
Enter Amount
Liabilities
Current Debt (Credit Card/Accounts) - Value in Dollars
Enter Amount
Notes Payable - Value in Dollars
Enter Amount
Taxes Payable - Value in Dollars
Enter Amount
Real Estate Mortgages - Value in Dollars
Enter Amount
Other Liabilities - Value in Dollars
Enter Amount
Total Liabilities - Value in Dollars
Enter Amount
Net Worth - Value in Dollars
Enter Amount
The financial information on this form is a true and correct statement of my current financial position to the best of my knowledge and belief. I further attest that I have not transferred and/or donated to another person's assets which are not reflected on this form within the past 5 years.
*
First Name
Middle Name
Last Name
In compliance with New York State and Federal laws which prohibit discrimination based on race, creed, color, national origin, age, sex, marital status, sexual preference, blindness, source of payment or sponsorship, this facility admits and treats all residents on a non-discriminatory basis. Completion and submission of this application does not ensure and/or guarantee admission. This facility is smoke free, no smoking is allowed in the facility or on the grounds. This completed form should be returned/submitted to Groton Community Health Care Center at 120 Sykes Street, Groton, NY 13073. Please contact us at 607-898-5876 if you have any questions.
Signature
*
List of Emails for Reply-All
Print
Save and Continue Later
Continue
Should be Empty: