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

    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













    MaleFemale



    YesNo

    YesNo




    YesNo


    YesNo




    YesNo










    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:


    YesNo



    YesNo

    YesNo

    YesNo

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












    YesNo

    YesNo

    YesNo

    C. Emergency Contact











    III. Insurance Coverage:


    YesNo

    YesNo








    YesNo

    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:

    Applicant Income









    Applicant Spouse Income











    YesNo

    V. Assets / Resources:


    YesNo



    SoleJoint


    YesNo


    YesNo





    YesNo



    YesNo


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





    YesNo

    VI. Liabilities:


    YesNo


    YesNo


    YesNo


    YesNo

    VII. Divesting:


    YesNo



    YesNo



    YesNo



    YesNo



    VIII. Counsel:


    Estate PlanningMedical Planning

    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

    1. Upon satisfactory review of the Questionnaire, including the representations and warranties made herein,
      The McGuire Group will consider the Resident for admission.
    2. 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.
    3. 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?
    4. 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.
    5. 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.
    6. 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.
    7. 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.
    8. 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.












    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.