Resident Application

Social Security Number

If no, what country are you a citizen of?

Medicare Number

Medicaid Number

Employer Name

Please list all languages that you speak.

I. General Information

If no, who handles these affairs?

Relationship to You

Why would you like to be considered for admission at Lincoln House?

What did you do for work most of your life?

What are your interests/hobbies?

Do you have any pets you would like to bring to Lincoln House with you?

Lincoln House has a specific pet policy we will discuss with you.

Vehicle Make & Model

State Where Registered

License Plate Number

If yes, please provide:

Name

Relationship

If yes, please provide:

Name

Relationship

Health Insurance

Medicare Number

If yes, list Policy Number:

If yes, please provide:

Name of Company

Policy Number

Brief Description

II. Functional Assessment

During the past six months, how many times have you seen a doctor?

How many days in the past six months were you in a hospital?

Why were you hospitalized?

If yes, describe:

If you selected any illnesses above that interfere with your daily activities, please elaborate here:

Please have your doctor send us a list of your medical diagnoses and medications that you are taking.

What other drugs have you taken in the past month?

If yes, please describe:

Are you allergic to any medications or foods? Please specify which reaction you experience.

Do you have dietary restrictions?

(No salt, sugar, etc.)

If yes, please explain:

How many hours each night do you usually sleep?

III. Financial Statement

A. Income

List all income from all sources, including but not limited to: Wages/Salary, Welfare, Social Security, Veteran's Pension, Worker's Compensation, Interest, Alimony, Annuities, Dividends, Proceeds from rental property, etc. Please include the source of income, amount received, how often it is received, and a name and address to verify.

How many people in total live on your income?

B. Assets

List all bank accounts, including savings and checking, stocks and bonds, CD's, cash value of life insurance, and all other assets with the exception of real estate. Please include name of asset, value, account number, and a name and address to verify.

Please submit income verification (by emailing gchinc@sover.net) such as income tax return, bank and asset statements (stocks, bonds, CD's), and if you own real estate, copy of tax bill.

C. Real Estate

List all real estate in which you have ownership interest. Please include Type & Address of Property, Fair Market Value, Mortgage Holder, and Mortgage Balance.

D. Expenses

List all expenses you pay on a regular basis (rent, car payments, household expenses, etc.). Please include to whom it's paid, amount owed, account number, and balance.

If yes, please explain:

G. State any other information which you would expect to be helpful in processing this application.

H. Do you as the responsible parties guarantee money for two years for Residency?

Medical Release Form

The information on this form is to be used by Lincoln House and its agents to assist in determining the eligibility and suitability of the applicant for residency at Lincoln House and which services may be required. We are required by our funding sources to document the eligibility of residents, and, for this reason, financial information on this form may be disclosed to these funding sources without additional notice to the applicant. By law, the Vermont Department of Health is entitled to resident's medical and health records for the purpose of licensing and certification.

LINCOLN HOUSE