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Financial Application

FINANCIAL APPLICATION

Ascension Living is committed to providing you with quality care and services. In order to accomplish this goal, we need your help in providing the information below. This application will become a part of the "Resident Agreement" and MUST be completed in its entirety. Ascension Living affords equal treatment and access to its facilities and services for all persons without unlawful discrimination due to race, color, religion, sex, age, national origin, ancestry, or disability. All information will be held in confidence.

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RESIDENT INFORMATION

Resident's Name:

Room #

Resident's Current Address:

Date of Birth:

Home Phone:

Work Phone:

Cell Phone:

Marital Status:

Spouse Name:

New Field:

Place of Birth:

Emergency Contact Name:

Emergency Contact Number:

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FINANCIAL RESPONSIBLE PARTY (to whom the bills will be sent)

Financial Responsible Party:

Relationship:

Financial Responsible Party's Address:

Home Phone:

Work Phone:

Cell Phone:

Email:

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CASH ASSETS

Bank Name:

Location:

Checking Account Balance:

Savings Account Balance:

Certificate of Deposit:

Value:

Maturity Date:

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REAL ESTATE

Does the resident own a home?

Yes

No

If yes, please provide the address:

Value of Home:

Does the resident own other properties?

Yes

No

If yes, please provide the address:

Value of Property:

Does the resident have rental income?

Yes

No

if yes, amount per month:

Value of mortgages embumbering any real estate owned:

Have you transferred or given away any real estate or assets within the last 5 years? If so, descibe:

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LIFE INSURANCE

DOES THE RESIDENT HAVE LIFE INSURANCE WITH CASH VALUE?

Yes

No

IF YES, PLEASE PROVIDE THE VALUE

DOES THE RESIDENT HAVE ANNUITIES?

Yes

No

IF YES, PLEASE PROVIDE THE VALUE

COMPANY NAME FOR ANNUITIES

AGENT’S NAME

AGENT’S PHONE

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SECURITIES

DOES THE RESIDENT HAVE STOCKS AND/OR BONDS?

YES

NO

IF YES, PLEASE PROVIDE THE VALUE

COMPANY NAME FOR SECURITIES

AGENT’S NAME

AGENT’S PHONE

COMPANY ADDRESS

CHECKING ACCOUNT BALANCE

SAVINGS ACCOUNT BALANCE

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OTHER MONTHLY INCOME

SOCIAL SECURITY?

YES

NO

AMOUNT:

PENSION?

YES

NO

AMOUNT:

LONG TERM CARE INSURANCE?

Option 1

NO

AMOUNT:

DISABILITY?

YES

NO

AMOUNT:

ANNUITIES/Retirement Plans?

YES

NO

AMOUNT:

OTHER?

YES

NO

AMOUNT:

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MONTHLY LIABILITIES

MORTGATE/RENT?

YES

NO

AMOUNT:

CAR PAYMENT?

YES

NO

AMOUNT:

LOANS?

YES

NO

AMOUNT:

CREDIT CARDS

YES

NO

AMOUNT:

OTHER

YES

NO

AMOUNT:

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HEALTH AND/OR LONG TERM CARE INSURANCE

Medicare Part A:

Medicare Part A

#

INSURANCE CARD:

Medicare Part B

Medicare Part B

#

INSURANCE CARD:

Managed Care:

Managed Care:

Name:

Policy #:

INSURANCE CARD:

Medicare Part D:

Medicare Part D

Name:

Policy #:

INSURANCE CARD:

Veterans Benefits:

Veterans Benefits

Policy #:

INSURANCE CARD:

Other Insurance 1

Other Insurance

Name:

Policy:

INSURANCE CARD:

Other Insurance 2:

Other Insurance

Name:

Policy:

INSURANCE CARD:

Medicaid:

Medicaid

Medicaid #:

INSURANCE CARD:

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Healthcare Providers

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Primary Care Physician

Name:

New Field:

Phone:

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Name:

Address:

Phone:

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Dentist

Name:

Address:

Phone:

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Optometrist

Name:

Address:

Phone:

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Podiatry

Name:

Address:

Phone:

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Pharmacy

New Field

Address:

Phone:

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Mortuary

Name:

Address:

Phone:

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Other Specialist

Name:

Address:

Phone:

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I (we) make this application for residence of my (our) own free will and accord. I (we) declare the information provided to the foregoing

questions to be true, complete, and an accurate financial account to the best of my (our) knowledge at time of completion.

Thank you for contacting us.
We will get back to you as soon as possible.

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Home
About
Services
Admission
- Financial Application
Our Facility
Visitor Info
Contact

Phone:

716.298.2900

Address:

5285 Lewiston Road

Lewiston, New York 14092-1942

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