Admission Application - The McGuire Group

Admission Application for Long-Term Residents and Rehab Patients

PLEASE NOTE: This is NOT an employment application. If you are interested in a career with The McGuire Group or one of our facilities, please visit the Career Opportunities page.

At The McGuire Group facilities, we understand the information that is listed on this application is privileged and highly confidential. Therefore, the information you send is encrypted to ensure it’s safe and secure delivery. Please be assured, the information you provide will be used solely in conjunction with the admission process. If you have any questions, please feel free to contact our Admissions Coordinator. Thank you.

To download a printable version of this application, click here.

I. Applicant Demographics:

* Required Fields

What facilities are you applying for? * Check all that apply.
Autumn View Health Care Facility, Hamburg, NYBrookhaven Health Care Facility, East Patchogue, NYGarden Gate Health Care Facility, Cheektowaga, NYHarris Hill Nursing Facility, Williamsville, NYNorthgate Health Care Facility, North Tonawanda, NYSeneca Health Care Center, West Seneca, NY

Name of Applicant *

Home Address *

City *

County *

State *

Zip *

Home Phone *

Cell Phone

Work Phone

Religion

Social Security Number

Gender
MaleFemale

Date of Birth

Place of Birth

U.S. Citizen
YesNo

If yes, is proof available?
YesNo

Marital Status

Spouse Name

Spouse Location

Applicant or Spouse Currently Employed?
YesNo

Location of Applicant

Previous nursing home stays?
YesNo

Previous Nursing Home Name

Dates of Stay

Recent hospital stay?
YesNo

Hospital Name

Dates of Stay

Reason for stay

Primary Physician Name

Practice Name

Practice Phone

Consulting Physician Name

Consulting Practice Name

Consulting Practice Phone

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:

Health Care Proxy?
YesNo

Name

Number

Other?

B. Financial/Designated Representative (manages finances for applicant)

Name

Relation

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

If Yes, please provide proof document

C. Emergency Contact

Name

Relation

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

III. Insurance Coverage:

Veteran
YesNo

Spouse Veteran
YesNo

Medicare

Medicare Effective Date Part A

Medicare Effective Date Part B

Medicaid County

Medicaid CIN #

Medicaid Effective Date

If Medicaid Pending, Interview Date:

Long-Term Care Insurance
YesNo

Provider

Other Medical Insurance (BC/BC, IHA, HCP, Univera, EPIC, No Fault)

Provide copies of all Insurance, Medicare, Pharmacy & Social Security cards

Company/Insurer

ID #

Monthly Premium

Medicare Part D Plan & ID

Prescription Drug Plan

IV. Statement of Income:

Applicant Income

Social Security Income

SSI Income

Retirement/Pension Income

Veteran's Pension

Railroad Income

Rental Income

Salary

Other Income

Applicant Spouse Income

Social Security Income

SSI Income

Retirement/Pension Income

Veteran's Pension

Railroad Income

Rental Income

Salary

Other Income

Specify Other Income Sources

Consent to change of address for Monthly Income
YesNo

V. Assets / Resources:

Real Estate
YesNo

Real Estate Location

Real Estate Value

Type of Ownership
SoleJoint

Joint with

Life Estate
YesNo

Year established

Life Insurance
YesNo

Face Value

Cash Value

Face Value

Cash Value

Prepaid Funeral
YesNo

Location

Phone

Trust
YesNo

Trust Name

Date Trust Established

Additional Assets / Resources - Applicant or Joint with Applicant - (Checking, Savings, CDs,stocks, bonds, annuities, money market, etc.)

Account Name

Type of Account

Balance

Are any of the above annuitized?
YesNo

Total Account Balance

VI. Liabilities:

Home Mortgage
YesNo

Amount Owed

Loans
YesNo

Amount Owed

Credit Cards
YesNo

Amount Owed

Other (home equity, etc.)
YesNo

Amount Owed

VII. Divesting:

Has applicant / financial representative transferred assets or property in the past 60 months to a life estate or to someone other than yourself?
YesNo

Asset(s) Value

Date of Transfer

Has applicant given gifts of money in the last 60 months?
YesNo

Monetary Gift(s) Value

Date of Gift

Has applicant issued any promissory notes
YesNo

Promissory Note(s) Value

Date of Issue

Has applicant been part of a Personal Care Agreement?
YesNo

Personal Care Agreement Description

Date of Agreement

Additional Financial Information

VIII. Counsel:

Are you currently working with an attorney or other firm for
Estate PlanningMedical Planning

What Firm?

I, the resident and/or the Designated Representative, each separately and individually, warrant that the financial information submitted to the facility concerning the Resident’s finances is true, accurate and complete in all material respects, and that there are no material omissions.

I/we acknowledge that The McGuire Group has relied and will continue to rely upon my/our truthful representation of all the Resident’s known income, assets, resources and liabilities, as well as my/our full disclosure of any transfers of income, and that my/our misrepresentation or failure to provide full disclosure may result in an interruption in payment or qualification for benefits for payment of expenses incurred by the resident.

The resident and/or Designated Representative assure payment of all expenses incurred to the extent of the applicant’s resources.

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.

By checking this box, I agree to submit this application electronically and understand that an electronic signature has the same legal status and can be enforced in the same way as a written signature.

Applicant's electronic signature *

Date*

Home Address *

City *

State *

Zip *

Representative's electronic signature *

Date*

Representative Home Address *

City *

State *

Zip *

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.