Masonic Village at Elizabethtown Application (Couples) 2024

Page 1

Masonic Village Application

All Masonic Villages are Non-Smoking

Elizabethtown LafayetteHill Sewickley Warminster

This application is being submitted for:

Personal Care = Minimal assistance with tasks of daily living, bathing, dressing, medication administration, appointment management

Nursing Care = Moderate to maximum assistance with tasks of daily living

Memory Support/Nursing Care = Moderate to maximum assistance with tasks of daily living, with a memory support area available for those in need at the Elizabethtown and Sewickley facilities.

Name of Applicant(s) Relationship to Member

Name of PA Mason or PA Eastern Star Member Initiation Date

Lodge or Chapter Name/#/Location

Failure to complete the application in its entirety or sign below can result in a delay in processing your application

 I certify the information contained in this application is correct and complete to the best of my knowledge and the resources listed are and will remain available to pay for all services provided by Masonic Village.

 I will not make any transfers or gifts subsequent to the date of this application for residency, including a transfer of assets to an irrevocable trust, or change the liquidity of my assets in any manner, including the purchase of an annuity, which would substantially impair my ability to timely fulfill my financial responsibility and financial obligations to Masonic Village. This provision will be enforced to the extent permitted by applicable law.

 I understand that any misrepresentation or willful omission of information on this application will disqualify the applicant for admission and may be cause for discharge if discovered after resident’s admission.

 I understand Masonic Village will screen all applicants against the applicable Megan’s Law website.

 Financial documentation & Medical Information must be provided as part of the application process

Signature of applicant and/or person completing this application:

Applicant #1 Signature

Signature: Date:

Decisions concerning admission, the provision of services and referrals of residents are not based on the applicant’s race, color, religion disability, ancestry, national origin, familial status, age, sex, limited English proficiency (LEP) or any other protected status.

Phone Date FOR OFFICE USE ONLY Application # Date Issued Megan’s Law Application # Date Issued Megan’s Law PC NC NC/MS TCU Approved Denied Hold
Person completing application Date Date
Applicant #2 Signature

PERSONAL INFORMATION – APPLICANT #1

Full Name Sex M F US Citizen Yes No

Date of Birth: Place of Birth

Address City State Zip

Type of Residence: Own Rent Live with family Personal Care Nursing Care

Home Phone # Cell Phone #

Email address

Previous Address

Veteran Yes No or Spouse of Veteran Yes No Branch

Former Occupation Retirement Date

Religious Affiliation:

Marital Status: Single Married Widowed Divorced Separated

1.Full Name of Spouse(living or deceased)

2.Full Name of Spouse(divorced or deceased)

Are you registered as: Organ Donor Lions Eye Bank Donor Humanity Gifts Donor

Social Security # Medicare #

Health Ins ID or Policy #

Drug Prescription Ins ID or Policy #

Medical Assistance #

Do you have Long-term Care Insurance? Yes No If yes, please complete information below:

Name of Insurance Co. Agreement/Policy # Effective Date
Coverage Premium Amount $ How
paid? Benefit Period Elimination Period Daily Benefit for Personal Care $ Daily Benefit for Nursing Care $ 1
of
often

Name of Financial Power of Attorney/Guardian

Address City State Zip

Home Phone # Cell Phone #

Email address

Name of Medical Power of Attorney/Medical Decision Person

Address City State Zip

Home Phone # Cell Phone #

Email address

1. Name: Relationship to Applicant

2. Name: Relationship to Applicant

(H) (W) (C)

3. Name: Relationship to Applicant

OF ATTORNEY OR GUARDIAN – APPLICANT #1
POWERS
NEXT OF KIN/EMERGENCY CONTACTS – APPLICANT #1 (Medical POA/Decision will be contacted first in event of serious illness or death)
Address: Phone: (H) (W) (C) E-mail Address:
Address: Phone:
E-mail
Address:
Address: Phone:
E-mail
FINAL ARRANGEMENTS – APPLICANT #1 Name of Funeral Home Phone # Address Have you prepaid arrangements into an Irrevocable Burial Fund? Amount $ Cemetery 1A
(H) (W) (C)
Address:

PERSONAL INFORMATION – APPLICANT #2

Full Name Sex M F US Citizen Yes No

Date of Birth: Place of Birth

Address City State Zip

Type of Residence: Own Rent Live with family Personal Care Nursing Care

Home Phone # Cell Phone #

Email address

Previous Address

Veteran Yes No or Spouse of Veteran Yes No Branch

Former Occupation Retirement Date

Religious Affiliation:

Marital Status: Single Married Divorced Separated

1.Full Name of Spouse(living or deceased)

2. Full Name of Spouse(divorced or deceased)

Are you registered as: Organ Donor Lions Eye Bank Donor Humanity Gifts Donor

Social Security # Medicare #

Health Ins ID or Policy #

Drug Prescription Ins ID or Policy #

Medical Assistance #

Do you have Long-term Care Insurance? Yes No If yes, please complete information below:

Name of Insurance Co. Agreement/Policy # Effective Date
Coverage Premium Amount $ How often paid? Benefit Period Elimination Period Daily Benefit for Personal Care $ Daily Benefit for Nursing Care $ 2
of

Name of Financial Power of Attorney/Guardian

Address City State Zip

Home Phone # Cell Phone #

Email address

of Medical Power of Attorney/Medical Decision Person Address City State Zip Home Phone # Cell Phone #

Email address

POWERS OF ATTORNEY OR GUARDIAN – APPLICANT #2
Name
NEXT OF KIN/EMERGENCY CONTACTS – APPLICANT #2 (Medical POA/Decision will be contacted first in event of serious illness or death)
Name: Relationship to Applicant Address: Phone: (H) (W) (C) E-mail Address: 2. Name: Relationship to
Address: Phone: (H) (W) (C) E-mail Address: 3. Name: Relationship to Applicant Address: Phone: (H) (W) (C) E-mail Address: FINAL ARRANGEMENTS – APPLICANT #2 Name of Funeral Home Phone # Address Have you prepaid arrangements into an Irrevocable Burial Fund? Amount $ Cemetery 2A
1.
Applicant
ASSETS Please include assets/income of spouse Check if Applicant 1 Applicant 2 Joint Checking $ $ Savings $ $ Money Mkt $ $ Certificates of Deposit $ $ Investment Acct. $ $ Savings Bonds $ $ IRA, 403B, etc. $ $ Annuities $ $ Trust $ $ Other $ $ REAL ESTATE Property Address #1: Names on Deed: Value: $ Property Address #2: Names on Deed: Value: $ LIFE INSURANCE Applicant 1 Applicant 2 Insurance Co. TypeofPolicy (circle) Group/WholeLife/Term Group/WholeLife/Term FaceValue $ $ CashValue $ $ Premium $ $ Insurance Co. TypeofPolicy (circle) Group/WholeLife/Term Group/WholeLife/Term FaceValue $ $ CashValue $ $ Premium $ $ 3
FINANCIAL INFORMATION

Within the past 5 years, immediately preceding the date of this application, have you or your spouse?

Had a judgment entered against you? Yes No

Paid bills for someone else? Yes No

Declared bankruptcy? Yes No

Transferred/Gifted Assets? Yes No

Opened a Revocable or Irrevocable Family Trust? Yes No

Had money or personal possessions taken without your knowledge? Yes No

Sold your interest in real estate, automobile, other assets? Yes No

If yes, to any of the above, please provide appropriate documentation, judgement, bankruptcy, trust documentation, settlement sheet, etc.

EQUAL HOUSING OPPORTUNITY STATEMENT

The Masonic Village is pledged to the letter and spirit of the U.S. Policy for the achievement of equal housing opportunity throughout the Nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status or national origin.

AUTOMOBILE(S) Applicant 1 Applicant
Year & Model Year & Model MONTHLY INCOME Applicant 1 Applicant 2 Social Security $ $ Civil Service $ $ Railroad Retirement $ $ Pension $ $ IRA $ $ Annuity $ $ Other $ $ LIABILITIES Applicant 1 Applicant 2 Mortgage Balance $ $ Hm Equity/LOC Balance $ $ Reverse Mortgage Bal. $ $ Rent $ $ Credit Cards $ $
2
4

DOCUMENT LIST - APPROVAL

REQUIRED PERSONAL DOCUMENTATION – PLEASE PROVIDE COPIES

Social Security Card

Medicare Card (even if you have an HMO or PPO)

Supplemental Insurance Card

Medicare Advantage Insurance Card

Medical Assistance Card

Drug Prescription Card

Dental Insurance Card

Photo ID, such as driver’s license, State ID, passport or other government issued photo

Financial Power of Attorney or Guardianship Papers

Medical Power of Attorney and/or Living Will

Revocable or Irrevocable Trust Document (all pages) if applicable

Pre-paid Irrevocable Funeral Expenses with funeral home of your choice. Current Lancaster County Medicaid maximum is $18,564.16

Required Financial Documentation as stated below and on page 2

Both Personal Care and Nursing Care applications are reviewed under:

 Medicaid guidelines which have a 5-year look-back period.

 Checks/Deposit/Withdrawals or Transfers written in amounts over $500 are questioned.

 We will contact you with any questions before the application is submitted for review.

 You will still be required to complete an application for Medicaid after admission.

Note: If you are on Medical Assistance (Medicaid) or have started the process in another nursing home in PA or on the PA MA Long-Term Services & Supports Program. Provide copy of the Medicaid approval. We do not need bank statements if this is approved or in process. If married, please provide a copy of the Resource Assessment Determination Letter also.

If you on Medical Assistance (Medicaid) in another State, then the financial documentation will be needed.

Note: If you are applying for Personal Care & assets are below $60,000 and there is no real estate, please be sure the application packet you have received is a Fraternal Care Application Packet for Financial Assistance – if not, please contact office and request the appropriate application and documentation list.

REQUIRED FINANCIAL DOCUMENTATION

1. Nursing Care/Nursing Care Memory Support: provide the items in Box #1

2. Personal Care & assets are above $60,000, provide the items in Box #2

3. Personal Care/Nursing Care or Nursing Care Memory Support and assets are over $500,000 (not including real estate, provide the items in Box #3

Note: If providing paper copies of the documentation above, it is not necessary to staple the documents. Copies can be provided via US Mail, using the enclosed envelope, thumb drive; confidential email or confidential fax

Email: mveadmissions@masonicvillages.org OR Fax: 717-361-5500 Page 1

BOX #1

Statements for all accounts (all pages) for current 12 months. This includes checking, savings, credit union, stocks, bonds, IRAs, 401Ks, CDs or other investments. Please provide check copies for any checks over $500

NOTE A: EVERY PAGE OF BANK STATEMENTS, INVESTMENT ACCOUNTS, ETC IS REQUIRED BY THE STATE, EVEN IF IT IS A BLANK PAGE, ADVERTISEMENT, RECONCILATION, ETC.

NOTE B: ANNUAL OR YEAR END INVESTMENT STATEMENTS (IF RECEIVED) CAN BE SUBSTITUTED FOR MONTHLY STATEMENTS. CURRENT STATEMENTS SHOULD BE PROVIDED FOR CURRENT YEAR

Verification of any accounts or resources closed or cashed in during the past 5 years and proof of where the Funds were deposited or spent

Real Estate – deed for property owned and/or title of mobile home OR settlement sheet if you have sold or transferred property within the past 5 years

Reverse Mortgage – provide documentation which includes payoff amount

Registration for motor vehicle(s)

Bankruptcy Documentation, or Judgement Documentation, if applicable

BOX #2

Statements for all accounts (all pages) for current 24 months, plus January & June statements for 2019, 2020 & 2021. This includes checking, savings, credit union, stocks, bonds, IRAs, 401Ks, CDs or other investments. Please provide check copies for any checks over $500.

NOTE A: EVERY PAGE OF BANK STATEMENTS, INVESTMENT ACCOUNTS, ETC IS REQUIRED BY THE STATE, EVEN IF IT IS A BLANK PAGE, ADVERTISEMENT, RECONCILATION, ETC.

NOTE B: ANNUAL OR YEAR END INVESTMENT STATEMENTS (IF RECEIVED) CAN BE SUBSTITUTED FOR MONTHLY STATEMENTS. CURRENT STATEMENTS SHOULD BE PROVIDED FOR CURRENT YEAR

Verification of any accounts or resources closed or cashed in during the past 5 years and proof of where the Funds were deposited or spent

Real Estate – deed for property owned and/or title of mobile home OR settlement sheet if you have sold or transferred property within the past 5 years

Reverse Mortgage – provide documentation which includes payoff amount

Registration for motor vehicle(s)

Bankruptcy Documentation, or Judgement Documentation, if applicable

Past 5 years

BOX #3

Statements for all accounts (all Pages) for current 6 months. This includes checking, savings, credit union, stocks, bonds, IRAs, 401Ks, CDs or other investments. Please provide check copies for any checks over $500.

NOTE A: EVERY PAGE OF BANK STATEMENTS, INVESTMENT ACCOUNTS, ETC IS REQUIRED BY THE STATE, EVEN IF IT IS A BLANK PAGE, ADVERTISEMENT, RECONCILATION, ETC.

NOTE B: ANNUAL OR YEAR END INVESTMENT STATEMENTS (IF RECEIVED) CAN BE SUBSTITUTED FOR MONTHLY STATEMENTS. CURRENT STATEMENTS SHOULD BE PROVIDED FOR CURRENT YEAR

2

Page

Date:

MASONIC VILLAGE MEDICAL DEMOGRAPHICS FORM

Name of Applicant:

CURRENT LIVING SITUATION

Resides: Home Apartment Lives w/Family Personal Care/Assisted Facility Nursing Facility

If residing at home/apt/family, do you have assistance at home? Yes No

If yes, is assistance provided by: Family Home Care How many hours per day?

If provided by Home Care staff – name of agency

Name of family physician

Specialists seen in the last 5 years:

Physician

Reason

Physician

Reason:

Physician

Reason

Hospitalizations within the past 5 years:

Hospital

PHYSICIAN INFORMATION

Phone #

Phone #

Phone #

Phone #

HOSPITALIZATIONS

Phone #

Reason Date Admitted Date Discharged

Hospital

Phone #

Reason Date Admitted Date Discharged

Hospital

Phone #

Reason Date Admitted Date Discharged

PSYCHIATRIC OR MENTAL HEALTH TREATMENTS

Past psychiatric or mental health treatments:

Physician or hospital name & address

Diagnosis

Physician or hospital name & address

Diagnosis

Date Admitted Date Discharged

Date Admitted Date Discharged 1

Name of Applicant:

OTHER FACILITIES

Have you resided in a nursing home, personal care or assisted living facility in the past 5 years? Yes No

Name & address of facility

Phone:

Reason Date Admitted Date Discharged

Name & address of facility Phone:

Reason Date Admitted Date Discharged

OTHER MEDICAL NEEDS

Check all which currently apply:

Oxygen: ______Liters:

Independent w/Oxygen Therapy Assistance needed with Oxygen Monitoring

C-Pap Dialysis

Catheter Care: Foley or Intermittent catheter

Bi-Pap Chemotherapy Colostomy/Urostomy

Pacemaker Feeding Tube Radiation

Wound Care Amputation/Prothesis

Brace/Cast/Splint Where

Organ Transplant Where

Dressings /specify Location & Treatment

Hospice Name of Hospice

How do you take your medications?

MEDICATIONS

Directly from pill container Weekly or Monthly pill box (mediset) Other

Do you need assistance with your medications? Yes No

If yes, what type of assistance?

2

ACTIVITIES OF DAILY LIVING NEEDS

Do you need any assistance with your activities of daily living? Yes No

Please use the key below and check off type of assistance needed:

I = Independent (no help or supervision needed)

S = Supervision (encouragement or cueing needed)

L = Limited (some light physical help needed)

E = Extensive physical help needed, can do some self-care) T =

physical help needed)

HEARING/VISION/SPEECH

Hearing: Normal Hard of Hearing Total Hearing Impairment

Do you wear hearing aids? Left Right

Vision: Wear glasses Wear contacts Mild/Moderate Vision Impairment

Total Vision Impairment

Speech: Normal Aphasia Expressive Receptive Other

BOWEL/BLADDER

Bladder Incontinence Bowel Incontinence If incontinent, do you handle yourself? Yes No

Continent, complete control

Usually continent, incontinence once a week or less

Occasionally incontinent, approximately 2 times per week, but not daily

Frequently incontinent, incontinent daily, but some control present

Incontinent, no control, multiple episodes

Incontinent, cannot manage independently

MOBILITY

Independent (uses no assistive devices) Uses Assistive Device (please check below)

Cane Walker Scooter Wheelchair Electric Wheelchair/Scooter for long distances only

Uses Electric Wheelchair/Scooter for all mobility needs Must use to go in Dining Room

What distance are you comfortable walking?

Can you do steps? 3

of Applicant:
Name
Bathing/Showering I S L E T
Dressing/Undressing I S L E T
Grooming/Hygiene I S L E T
Total Assistance
Eating/Drinking I S L E T Transferring out of bed chair I S L E T Toileting I S L E T
(full

DIETARY NEEDS

Do you follow any dietary restrictions?

Vegetarian Low Carbohydrate Paleo Gluten Free Religious-based

Other:

Have you been diagnosed with an allergy to any foods?

Wheat Soy Shellfish Finfish Milk Tree Nuts Peanuts

Eggs Other: TOBACCO/ALCOHOL USE

Do you currently smoke? Yes No

Are you a previous smoker? Yes No

When did you stop smoking?

Do you drink alcohol? Yes No How often?

COGNITIVE STATUS

Behavior

Name of Applicant:
Alert Forgetful Pleasant Confused Cueing Needed Orientation: Time No Problem Sometimes a problem Often a problem Place No Problem Sometimes a problem Often a problem Person No Problem Sometimes a problem Often a problem Recent memory No Problem Sometimes a problem Often a problem Distant memory No Problem Sometimes a problem Often a problem Able to take direction No Problem Sometimes a problem Often a problem Wandering behavior No Problem Sometimes a problem Often a problem Verbally abusive No Problem Sometimes a problem Often a problem Physically abusive No Problem Sometimes a problem Often a problem
behavior, ex. yelling out No Problem Sometimes a problem Often a problem
Inappropriate/disruptive
issues
4
not listed above:

Date:

MASONIC VILLAGE MEDICAL DEMOGRAPHICS FORM

Name of Applicant:

CURRENT LIVING SITUATION

Resides: Home Apartment Lives w/Family Personal Care/Assisted Facility Nursing Facility

If residing at home/apt/family, do you have assistance at home? Yes No

If yes, is assistance provided by: Family Home Care How many hours per day?

If provided by Home Care staff – name of agency

Name of family physician

Specialists seen in the last 5 years:

Physician

Reason

Physician

Reason:

Physician

Reason

Hospitalizations within the past 5 years:

Hospital

PHYSICIAN INFORMATION

Phone #

Phone #

Phone #

Phone #

HOSPITALIZATIONS

Phone #

Reason Date Admitted Date Discharged

Hospital

Phone #

Reason Date Admitted Date Discharged

Hospital

Phone #

Reason Date Admitted Date Discharged

PSYCHIATRIC OR MENTAL HEALTH TREATMENTS

Past psychiatric or mental health treatments:

Physician or hospital name & address

Diagnosis

Physician or hospital name & address

Diagnosis

Date Admitted Date Discharged

Date Admitted Date Discharged 1

Name of Applicant:

OTHER FACILITIES

Have you resided in a nursing home, personal care or assisted living facility in the past 5 years? Yes No

Name & address of facility

Phone:

Reason Date Admitted Date Discharged

Name & address of facility Phone:

Reason Date Admitted Date Discharged

OTHER MEDICAL NEEDS

Check all which currently apply:

Oxygen: ______Liters:

Independent w/Oxygen Therapy Assistance needed with Oxygen Monitoring

C-Pap Dialysis

Catheter Care: Foley or Intermittent catheter

Bi-Pap Chemotherapy Colostomy/Urostomy

Pacemaker Feeding Tube Radiation

Wound Care Amputation/Prothesis

Brace/Cast/Splint Where

Organ Transplant Where

Dressings /specify Location & Treatment

Hospice Name of Hospice

How do you take your medications?

MEDICATIONS

Directly from pill container Weekly or Monthly pill box (mediset) Other

Do you need assistance with your medications? Yes No

If yes, what type of assistance?

2

ACTIVITIES OF DAILY LIVING NEEDS

Do you need any assistance with your activities of daily living? Yes No

Please use the key below and check off type of assistance needed:

I = Independent (no help or supervision needed)

S = Supervision (encouragement or cueing needed)

L = Limited (some light physical help needed)

E = Extensive physical help needed, can do some self-care) T =

physical help needed)

HEARING/VISION/SPEECH

Hearing: Normal Hard of Hearing Total Hearing Impairment

Do you wear hearing aids? Left Right

Vision: Wear glasses Wear contacts Mild/Moderate Vision Impairment

Total Vision Impairment

Speech: Normal Aphasia Expressive Receptive Other

BOWEL/BLADDER

Bladder Incontinence Bowel Incontinence If incontinent, do you handle yourself? Yes No

Continent, complete control

Usually continent, incontinence once a week or less

Occasionally incontinent, approximately 2 times per week, but not daily

Frequently incontinent, incontinent daily, but some control present

Incontinent, no control, multiple episodes

Incontinent, cannot manage independently

MOBILITY

Independent (uses no assistive devices) Uses Assistive Device (please check below)

Cane Walker Scooter Wheelchair Electric Wheelchair/Scooter for long distances only

Uses Electric Wheelchair/Scooter for all mobility needs Must use to go in Dining Room

What distance are you comfortable walking?

Can you do steps? 3

of Applicant:
Name
Bathing/Showering I S L E T
Dressing/Undressing I S L E T
Grooming/Hygiene I S L E T
Total Assistance
Eating/Drinking I S L E T Transferring out of bed chair I S L E T Toileting I S L E T
(full

DIETARY NEEDS

Do you follow any dietary restrictions?

Vegetarian Low Carbohydrate Paleo Gluten Free Religious-based

Other:

Have you been diagnosed with an allergy to any foods?

Wheat Soy Shellfish Finfish Milk Tree Nuts Peanuts

Eggs Other: TOBACCO/ALCOHOL USE

Do you currently smoke? Yes No

Are you a previous smoker? Yes No

When did you stop smoking?

Do you drink alcohol? Yes No How often?

COGNITIVE STATUS

Behavior

Name of Applicant:
Alert Forgetful Pleasant Confused Cueing Needed Orientation: Time No Problem Sometimes a problem Often a problem Place No Problem Sometimes a problem Often a problem Person No Problem Sometimes a problem Often a problem Recent memory No Problem Sometimes a problem Often a problem Distant memory No Problem Sometimes a problem Often a problem Able to take direction No Problem Sometimes a problem Often a problem Wandering behavior No Problem Sometimes a problem Often a problem Verbally abusive No Problem Sometimes a problem Often a problem Physically abusive No Problem Sometimes a problem Often a problem
behavior, ex. yelling out No Problem Sometimes a problem Often a problem
Inappropriate/disruptive
issues
4
not listed above:
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