Consulting Physician Name
Consulting Practice Name
II. Responsible Party/Emergency Contacts:
The McGuire Group requests that to the greatest extent feasible, the individual named as the Financial/Designated Representative for the applicant to be an existing attorney-in-fact for the applicant, or be granted a Durable Power of Attorney by the applicant as soon as possible to ensure continuity of payment of all expenses incurred to the extent of the applicant's resources.
A. Advanced Directives:
B. Financial/Designated Representative (manages finances for applicant)
C. Emergency Contact
III. Insurance Coverage:
Other Medical Insurance (BC/BC, IHA, HCP, Univera, EPIC, No Fault)
Provide copies of all Insurance, Medicare, Pharmacy & Social Security cards
IV. Statement of Income:
V. Assets / Resources:
Additional Assets / Resources - Applicant or Joint with Applicant - (Checking, Savings, CDs,stocks, bonds, annuities, money market, etc.)
REPRESENTATIONS, WARRANTIES AND INDEMNIFICATION AGREEMENT
Upon satisfactory review of the Questionnaire, including the representations and warranties made herein,
The McGuire Group will consider the Resident for admission.
The Resident and Representative each acknowledge The McGuire Group’s reliance on the statements made
by them in the Admission Questionnaire and the promises made herein and agree to indemnify and hold
The McGuire Group harmless from any and all liability, loss, expense, and/or damage which The McGuire
Group may incur by reason of any misrepresentation contained in either document or their noncompliance
with either document.
The Resident and Representative represent and warrant to The McGuire Group that the Resident’s assets are fully
and accurately disclosed on the Questionnaire and that there have been no transfers of the Resident’s ownership
interest in any assets or resources within the past 60 months for which fair payment has not been received other than
those listed in section VII?
The Resident and Representative agree that neither of them has previously done anything nor will either of them at
any time hereafter do anything that would cause the Resident to become ineligible or disqualified for Medicaid for any
period of time whether by reason of having transferred the Resident’s present or future acquired assets without
receiving fair payment or value in exchange for such transfer or otherwise.
If the Resident is the owner of a residence, the Resident and Representative represent and warrant that if and when
the Resident no longer intends to return to such residence, such residence will be promptly sold for fair value and the
proceeds used to discharge Resident’s obligations to The McGuire Group if and when other resources are exhausted.
Prior to exhausting Resident’s other assets, they will list the residence for sale (with an M-L broker) for its then fair
market value and diligently pursue the closing of a sale of the residence. The proceeds of sale will be held and used
solely for discharging Resident’s legal obligations, including the obligations to The McGuire Group.
The Resident and Representative agree that prior to exhausting the Resident’s assets and resources, they will make
timely application for Medicaid. The application shall be made in such manner and at such time that the Resident will be
able to pay his/her obligations to The McGuire Group by means of the Resident’s assets and resources and/or medical
assistance provided by the State of New York or other government agency.
If the Resident is denied timely Medicaid coverage due to the willful or negligent failure of Resident and/or
Representative to abide by this Agreement, they agree to indemnify and hold The McGuire Group harmless of and
from any and all loss or damage occasioned by any misrepresentation or failure to qualify for Medicaid and they each
agree to pay and reimburse The McGuire Group unconditionally all amounts that The McGuire Group would have
received had a timely Medicaid pick-up date occurred.
The liability of the Resident and the Representative for all damages incurred by The McGuire Group as a result of
the breach by either of them of any of the covenants and representations made herein will be joint and several. Nothing
herein, however, shall be construed to be a personal guaranty by the Representative of the obligations of
the Resident to The McGuire Group for the room, board and/or care provided to Resident at The McGuire
Group except to the extent that such obligation arises as a result of a breach of the covenants made herein.
I have reviewed the information contained herein, and represent that it is factually true, accurate and complete. I understand that The McGuire Group utilizes this information in the admissions decision process. The above terms and conditions will become effective and be binding upon and enforceable against the Resident and the Representative upon The McGuire Group’s admission of the Resident pursuant to this Questionnaire, the terms and provisions of which are hereby agreed to by The McGuire Group, the applicant and the applicant's representative.
The McGuire Group and its facilities do not discriminate in the admission, retention or care given to patients/residents in terms of age, race, creed, color, national origin, marital status, gender, gender identity, sexual preferences, handicap, blindness, disability or sponsor.