Valley View Retirement Community Skilled Nursing Application

Thank you for your interest in learning more about the services offered within our Skilled Nursing Center. We understand that choosing the right care partner is an important decision, and we truly appreciate the trust you place in exploring your options with us. Our goal is to serve as a supportive resource as you navigate this process. An important step is the completion of the application as it helps to us better understand your interest, to review financial requirements, and to seek medical information to help us better understand current needs. Please do not hesitate to contact me with any questions you may have. Kammi Booher, Community Admission Guide; 717-935-2105, ext. 1450; [email protected]

Valley View Retirement Community (VVRC) will comply with all applicable federal and state anti-discrimination requirements with respect to its admissions and provision of services.

Application Submitted For:(Required)
If selecting more than one, please rank them in order of preference.
I am ready to move in as soon as possible (Select One)(Required)
APPLICANT:(Required)
MM slash DD slash YYYY
STATUS(Required)
ADDRESS INFORMATION(Required)

HOW DID YOU HEAR ABOUT VALLEY VIEW RETIREMENT COMMUNITY?

Resident Representative 1(Required)
Address(Required)

Emergency Contact 1(Required)
Address(Required)

Emergency Contact 2(Required)
Address(Required)

MEDICAL/INSURANCE INFORMATION(Required)
Medicare Number(Required)
Medicare Number
Social Security Number
Supplemental Insurance Company
Medicare Advantage/PPO
Medicare Part D or Pharmacy Plan

Medical History

Do we have permission to access your medical records?(Required)
Have you ever received mental health services?
Mental Health
Have you been admitted to an inpatient nursing facility in the last 90 days?(Required)
NURSING HOME/CARE FACILITY
Have you been admitted to a hospital in the last 30 days?(Required)
HOSPITAL

Financial Disclosure Statement

Assets: Please fill out each entry. If an entry is not applicable, enter 0.

1. CHECKING(Required)
Applicant
Joint
Total
2. SAVINGS/MONEY MARKET(Required)
Applicant
Joint
Total
3. CDS(Required)
Applicant
Joint
Total
4. MUTUAL FUNDS(Required)
Applicant
Joint
Total
5. STOCKS & BONDS(Required)
Applicant
Joint
Total
6. RETIREMENT FUNDS(Required)
Applicant
Joint
Total
7. TRUST FUND(Required)
Applicant
Joint
Total
Indicate amount that is available for your care.
8. ANNUITIES CASH VALUE(Required)
Applicant
Joint
Total
Indicate cash value that you can withdraw from the annuity without penalty.
9. LIFE INSURANCE CASH VALUE(Required)
Applicant
Joint
Total
Indicate the cash surrender value of a life insurance policy.
10. BURIAL RESERVE(Required)
Applicant
Joint
Total
11. OTHER
Applicant
Joint
Total

12. REAL ESTATE
If you do not have a recent appraisal of your home, use Zillow.com or Trulia.com to estimate market value. Sale of house may be required to meet criteria.

ADDRESS(Required)
RESIDENCE MARKET VALUE $(Required)
$
13. Have you (or your spouse) transferred any assets including real estate, to someone other than your spouse for less than full market value within the past five years?(Required)
Have you or your spouse transferred any assets into a trust within the past five years?(Required)

14. Liabilities/Debt

MORTGAGE BALANCE
Applicant
Joint
Total
CREDIT CARD BALANCE
Applicant
Joint
Total
CAR LOAN BALANCE
Applicant
Joint
Total

15. Net Income

SOCIAL SECURITY(Required)
Applicant/Month
Joint/Month
Total/Month
PENSION(Required)
Applicant/Month
Joint/Month
Total/Month
If you are married, indicate what portion of your pension will remain for your spouse in the event of your death.
RIGHT OF SURVIVORSHIP(Required)
PERCENTAGE %
OTHER INCOME
Applicant/Month
Joint/Month
Total/Month
16. MONTHLY EXPENSES(Required)
Expenses
Applicant
Joint
Total
Only list monthly expenses that will continue while at VVRC.
MONTHLY EXPENSES
Expenses
Applicant
Joint
Total
MONTHLY EXPENSES
Expenses
Applicant
Joint
Total
MONTHLY EXPENSES
Expenses
Applicant
Joint
Total

Long Term Care Insurance

AGREEMENT
I understand that Valley View Retirement Community (VVRC) will keep my information in strict confidence and will only use the information for necessary purposes. I understand that VVRC may request proof of financial status and periodic updated financial information. All applications are reviewed when admission is pending and updates will be required at that time. Applicants must meet the financial criteria in place at the time a residence is available for occupancy. All of the assets listed in this application as owned or controlled by me are entitled or registered in my individual or joint names, or held for my benefit, and are available to pay for all levels of care at VVRC. I have full power and authority to convey or utilize such assets for my personal support and for payment for services supplied through VVRC. I affirm that I (or my/our agent(s) will not deplete or jeopardize such assets below the level of that reasonably required to provide for my care, or substantially change the nature or liquidity of my assets. I acknowledge that if I jeopardize my ability to pay for my care, then I may be ineligible for admission to any level of care at VVRC and may be ineligible for financial assistance from VVRC, and I may jeopardize my ability to live at VVRC. I understand that it is the policy of VVRC to screen all incoming applicants against the National Sex Offender Registry Website. I understand that VVRC will deny admission to anyone listed on federal and/or state sex offender registry websites. I understand and acknowledge that VVRC relies on the information and disclosures made in this application for the purpose of inducing VVRC to consider me for admission. I certify that the information and disclosures provided in this application are true, correct, and complete to the best of my knowledge and belief. Although the application is not otherwise binding, I understand and agree that any misrepresentation or significant omission or misstatement of fact, including financial information, may be considered grounds for refusal of residency or dismissal after admission.
APPLICANT OR REPRESENTATIVE
Clear Signature
MM slash DD slash YYYY