ASVH Admissions Online Application Logo

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  • Open printable file

    If you have any questions, please contact our Admissions Office.

    Phoenix

    Tucson

    Yuma

    Flagstaff 

    602-248-1594

    520-638-2150

    602-234-5678

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    Have a question before we start? Try here first:

    Frequently Asked Questions

     

    These are the documents you will need to provide:

    Open Documents Checklist printable version

     

    To be admitted, copies of the following documents are required. You can upload scanned files at the end of this application.

    IDENTIFICATION

    • DD Form 214: Certificate of Discharge
    • Birth Certificate
    • Driver’s License/Identification Card (State Issued)
    • Social Security Card

    MEDICAL INSURANCE

    • Arizona Health Care Cost Containment System (AHCCCS) Card
    • Medicare Card
    • VA Medical Card
    • Dental or Other Insurance Card

    MEDICAL RECORDS

      1. History and Physical
    2. TB clearance
    3. PASSR
    4. Wound Care
    5. Infection information
    6. Discharge instruction
    7. Immunization records
    8. Physician Progress notes
    9. Therapy notes
    10. Diet order
    11. IV Fluid/access    		 12. ABT
    13. Dialysis
    14. Scripts
    15. Nurses notes
    16. Therapy Notes
    17. Covid test within 48 hours of admission
    18. Covid vaccine history
    19. Physician's statement, coming from home.
    20. Physician's Certification

    LEGAL/OFFICIAL PAPERS

    • Advanced Directives
    • Power of Attorney and/or Durable Power of Attorney
    • Marriage Certificate (if currently married)
    • Final Divorce Decree (if applicable)
    • Pre-Arranged Burial Plan
    • Will or Trust

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    Complete this form to the best of your ability. If you have any questions as you go through it, call us 602-234-5678. 

    • All sections must be completed. However, your information is saved as you go through the form, so you have the option of coming back at a later time to complete any unfinished areas.
    • There is a separate, downloadable physician’s certification form. That must be completed as a hard-copy form by the applicant’s primary health care provider. The link for that form is below. When completed, that form can be mailed, faxed, or hand-delivered to the nearest Arizona State Veterans’ Home.

    Open/download Physician's Certification Form

    • Veterans and their spouses may apply together, but they must do so on separate forms.
    • All documents requested must be either digitally uploaded in this form or hard-copy delivered to the Arizona State Veterans’ Home of the applicant’s choice.  Hard copies can be mailed or hand-delivered.

     

    Arizona State Veteran Home - Phoenix

    4141 North Silvestre Herrera Way, Phoenix, AZ 85012

    Arizona State Veteran Home - Tucson

    555 East Ajo Way, Tucson, AZ 85713

    Arizona State Veteran Home – Yuma

    2100 N Gemini Rd, Flagstaff, AZ 86004

    Arizona State Veteran Home - Flagstaff

    6051 E 34th Street, Yuma, AZ 85365

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    Thank you for applying to join us at one of our Arizona State Veterans' Homes!

    To be admitted to one of our Homes, the applicant must be either a Veteran, a Veteran spouse, a surviving spouse, or an immediate Gold Star family member. In addition, they must provide the following information:

    • Complete a separate application for the Veteran and any spouse wishing to join him or her;
    • Completion of this online admission application, or the completion of a printed version;
    • Include of copy of the Veteran's discharge document from the United States military, a certified copy of the separation or discharge document from the National Personnel Records Center, or a Statement of Service issue by the Veterans Administration Regional Office;
    • If requested by the director of nursing, a copy of medical records that assist in determining the level of care required by the applicant. 

    NOTE: Evidence of treatment at a Veterans' Administration Medical Center may satisfy many of there requirements

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    General Information

  •  - -

  • Veteran's Service Information

  •  - -
  •  - -

  • Insurance

  • Advanced Planning

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  • Phoenix

    Hand-delivery or mailing address:
    AZ State Veterans Home Phoenix
    4141 N. S Herrera Way,
    Phoenix, AZ 85012

    Admissions
    Office #: 602-248-1594
    Fax #:602-263-1826

    Yuma

    Hand-delivery or mailing address:
    AZ State Veterans Home Phoenix
    6051 E 34th St,
    Yuma, AZ 85365

    Admissions
    Office #: 602-234-5678
    Fax #:928-569-5712

    Tucson

    Hand-delivery or mailing address:
    AZ State Veterans Home Phoenix
    555 East Ajo Way, Tucson
    AZ 85713

    Admissions
    Office #: 520-638-2150
    Fax #:602-773-0935

    Flagstaff

    Mailing Address:
    AZ State Veterans Home Phoenix

  • Applicant/Legal Representative: Read the following and Sign:

    I further declare that I am a legal resident of the State of Arizona. I will submit a copy of Honorable or General discharge documentation from the military service of the United States. I will inform the ASVH of any and all changes in my income and/or assets. I will
    obey the rules and regulations prescribed for the ASVH.

    I hereby authorize the ASVH to obtain all medical records from my physician, hospital, clinic or nursing home pertaining to my potential admission to the facility. These records may include, but are not limited to, diagnostic/laboratory results, consultant and progress
    notes/reports, assessment tools/reports, read mission screening documents, documentation for Medicare benefits and any other items specified by the ASVH.

  • Clear
  •  - -

  • Admission shall be in accordance with Title VI of the Civil Rights Act of 1964 as amended;
    Section 504 Rehabilitation Act of 1973 as amended; the Age Discrimination Act of 1975; the Age Discrimination Act of 1967; the American’s with Disabilities Act of 1990; and Arizona Administrative Code Title 4 Charter 40.

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  • Income Information

    The following information is required to process your application for admission to the Arizona State Veteran Home. If this information is incomplete, it will delay consideration of your application. If questions are not applicable, please indicate with the abbreviation “N/A”. Information submitted is subject to verification. The Arizona State Veteran Home reserves the right to request verification of any funds received by copies of award forms or award letters.

  • Clear

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    Physician's Certification

    The next section is completed and signed by the applicant’s physician. This certification is valid for 6 months from the date of completion. All information must be current and complete to avoid delays in processing. Please attach a copy of the patient’s current (completed within the last 3 months) History and Physical (H&P) as well as a current TB test. Medications must be listed on this form or supplemented with a typed medication list that is signed by the physician.

    Open/download Physician's Certification File

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    Functional Assessment

    For each area of functioning listed below, please describe to the best of your ability the amount and type of assistance the applicant currently requires.

     

  • Other Health Considerations

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    Files (or Photos) Upload

    • To upload multiple files, please use the box at the bottom of this page.
    • These files are acceptable: Word files (doc or docx), PDF, Text files, Image files (jpg, jpeg, png, etc.)
    • File size - no more than 2Mb

  • IDENTIFICATION

    • DD Form 214: Certificate of Discharge
    • Birth Certificate
    • Driver’s License/Identification Card (State Issued)
    • Social Security Card
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • MEDICAL INSURANCE

    • Arizona Health Care Cost Containment System (AHCCCS) Card
    • Medicare Card
    • VA Medical Card
    • Dental or Other Insurance Card
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Please use the box below to upload these files.

     

    MEDICAL RECORDS - upload all that are applicable

    1. History and Physical
    2. TB clearance
    3. PASSR
    4. Wound Care
    5. Infection information
    6. Discharge instruction
    7. Immunization records
    8. Physician Progress notes
    9. Therapy notes
    10. Diet order
    11. IV Fluid/access    		 12. ABT
    13. Dialysis
    14. Scripts
    15. Nurses notes
    16. Therapy Notes
    17. Covid test within 48 hours of admission
    18. Covid vaccine history
    19. Physician's statement, coming from home.
    20. Physician's Certification
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • LEGAL/OFFICIAL PAPERS

    • Advanced Directives
    • Power of Attorney and/or Durable Power of Attorney
    • Marriage Certificate (if currently married)
    • Final Divorce Decree (if applicable)
    • Pre-Arranged Burial Plan
    • Will or Trust

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • We will send a printed copy to:

    {name57}

    {address56}

  • Summary of Application

    Full Name {SectionA_name}
    Address {address}
    Email Address {email}
    Phone Number {phoneNumber}
    Gender {gender}
    Birth Date {birthDate}
    Birth Place {birthPlace}
    Ethnicity {ethnicity}
    Religious Preference {religiousPreference}
    Marital Status {maritalStatus}
    Spouse Name {spouseName}
    Occupation {occupationif}
    Enlistment Date {enlistmentDate}
    Discharge Date {dischargeDate}
    Branch {branch}
    Branch {checkAll97}
    Service-related Disability  {ifThere}
    Vet Service Representation  {ifRepresented}
    Armed Services {armedServices}
    VA Claim Number  {vaClaim}
    Medicare Number {medicareNumber}
    Medicare Coverage {medicareCoverage}
    AHCCCS Plan ID {ahcccsPlan}
    ALTCS PID {altcsPid}
    ALTCS Case Number {altcsCase}
    Advance Directive {advanceDirectives}
    Agent/Attorney Information {agentattorneyInformation}
    Funeral Information {funeralInformation}
    Cemetery Information {cemeteryInformation119}

     

    Documents Submit Option {howDo}
    Multi-site Application Preference {whichState}
    State Home Preference {singlesitePreference}
      {typeA45}
    Signature of the person filling out this Form {signatureOf}
    Signature Date  {date}

     

     Pay Option {payOption}
     Source of Income {a}
      {typeA143}
      {e}
      {incomeCompletion}

     

     Bathing {whatBathing}
      {bathingAssistance}
      {bathingFrequency128}
      {bathingFrequency}
      {howMuch}
     Toileting {toiletingAssistance}
      {toiletingInformation}
      {ifUnable}
     Mobility {howMobile}
      {ifAssistance}
     Eating {doesThe}
      {ifThe}
     Prostheses {doesThe159}
     Skin Irritation {doesThe160}
     Alert and Orientation {howAlert}
      {isThe}
     Other Health Information {ifThe163}
      {ifThe166}
      {ifThe167}
      {ifThe168}
      {ifThe171}
      {additionalInformation}

    Document Files

    {fileUpload69}

    {typeA183}

    {birthCertificate}

    {driversLicenseidentification}

    {socialSecurity}

    {fileUpload70}

    {typeA187}

    {medicareCard}

    {vaMedical}

    {dentalOr}

    {fileUpload71}

    {fileUpload72}

     

    {isYour}

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