Admission Application

Choose a Residence*
Select a Service*
- Full Time Residence
- Adult Day Care
- Respite Care
- Partners in Care Home Care
I. Personal Data
Name*
Phone*
Where is Applicant presently?*
Facility name (if any)
How long has the Applicant lived at the above address?*
Is the Applicant's home address the same as above?*
- Yes
- No
Home address (if different from the above address)*
Date of birth*
Marital status*
- Single
- Married
- Widowed
- Separated
- Divorced
Name of spouse (even if deceased)*
Date of spouse's birth*
List nearest relative(s)*
First & Last Name Relationship Address City, State, Zip Phone
Was Applicant ever in the U.S. Armed Services?*
- Yes
- No
Dates of service
Branch of service
ID Number
Attending physician*
Attending physician address*
Attending physician phone*

III. Statistical Data
Details including the Applicant's Social Security Number, Medicaid Number, and Medicare Number will be collected by the case manager at a later time.
Other Insurance
Prescription Coverage
Who shall be notified in case of serious illness or death? (Include business phone if appropriate)*

IV. Social Data
What are the Applicant's present living arrangements?*
Does the Applicant prepare their own meals and care for their own person without assistance?*
Is the Applicant on a special diet?*
- Yes
- No
Please specify:*
Why does the Applicant desire residence?*
Is the Applicant receiving any assistance at home at this time?*
- Yes
- No
If yes, briefly describe:*
Agency Name & Address:*

V. Mental Health Data
Does the Applicant have a history of mental health diagnosis?*
- Yes
- No
Type of diagnosis:*
Mental health doctor:*
How often does Applicant see their mental health doctor?*
Has Applicant ever been hospitalized for mental health issues?*
- Yes
- No
Last date and duration of hospitalization:*
Hospital*

Please check all that apply*
- Health Care Proxy
- Living Will
- POA
- DNR/Advance Directive
- Medicaid Managed Care
- None of the above
Signature*
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 Tanglewood Group has relied and will continue to rely upon my/our truthful representation of all of 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 in qualification for benefits for payment of expenses incurred by the resident.
Representations, Warranties and Indemnification Agreement
Upon satisfactory review of the Admission Application, including the representations and warranties made herein, The Tanglewood Group will consider the Resident for admission.

The Resident and Designated Representative each acknowledge The Tanglewood Group’s reliance on the statements made by them in the Admission Application and the promises made herein and agree to Indemnify and hold The Tanglewood Group harmless from any and all liability, loss, expense, and/or damage which the Tanglewood Group may incur by reason of any misrepresentation contained in either document or their noncompliance with other document. The Resident and Designated Representative represent and warrant to The Tanglewood Group that the Resident’s assets are fully and accurately disclosed on the Admission Application and that there have been no transfers of the Resident’s ownership interest in any assets or resources with the past 60 months for which fair payment has not been received other than those listed.

The Resident and Designated 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.

The Resident and Designated Representative, collectively and individually, represent and warrant to The Tanglewood Group that all assets listed in Section II Financial Data are titled and held solely in the name of the Resident, except as otherwise specifically stated in said Section II Financial Data.

The Resident and Designated Representative, collectively and individually represent and warrant to The Tanglewood Group that neither the Resident nor the Designated Representative has caused a transfer of any assets of Resident to a trust or trusts. The Resident and Designated Representative represent, warrant and agree that neither Resident nor Designated Representative, for a term of at least five consecutive years hereafter, will cause assets of the Resident to be transferred to a trust or to any other transferee for less than fair and adequate consideration. Any transfer by Resident and/or Designated Representative of assets owned, in full or in part, by the Resident to a trust that is not fully revocable and/or which does not include a retained unconditional and unlimited power in favor of the Resident to cause the Trustee to distribute the full corpus of such trust(s) to Resident shall be deemed a transfer for less than fair and adequate consideration.

Resident and Designated Representative, collectively and individually, warrant and represent to each Tanglewood Group adult care facility identified on the first page of this Admissions Agreement, collectively and individually a "Facility", that (i) Resident has sufficient net assets and will have sufficient net assets to fully pay the Facility for all rent, charges and expenses due the Facility pursuant to its Admissions Agreement with Resident on a private pay basis, and without medicaid, SSI or other third party/governmental reimbursement program for a term of at least two (2) years from the date of this Admission Application and (ii) Resident and the Designated Representative will not voluntarily permit or authorize any transfer, gift or depletion of the Resident's assets and/or any increase of the Resident's liabilities other than those asset transfers/increases to liabilities resulting from for the daily and customary living expenses of the Resident.
Signature
All representations, warranties, promises and covenants of the Resident and the Designated Representative contained herein shall survive any subsequent entry by The Tanglewood Group and Resident and/or Designated Representative into any residency agreement for admission of Resident into any Tanglewood Group facility as identified on the first page hereof.

The Resident and Designated 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 tha the Resident will be able to pay his/her obligations to The Tanglewood 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.

The Designated Representative represents, warrants and promises to the The Tanglewood Group that he/she will not accept transfer of or retain any assets from the Resident for less than fair and adequate consideration, outright and/or in trust, for a term of 60 months on and after the date of this application.

All such assets received by the Designated Trust shall be held by the Designated Representative for the benefit of The Tanglewood Group. If the Resident is denied timely Medicaid coverage due to the willful or negligent failure of Resident and/or Designated Representative to abide by this Agreement, they agree to indemnify and hold The Tanglewood 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 Tanglewood Group unconditionally all amounts that The Tanglewood Group would have received had a timely Medicaid pick-up date occurred.

The representations, warranties, promises and covenants of the Resident and Designated Representative contained herein in favor of The Tanglewood Group shall inure to the benefit of, collectively and individually, The Tanglewood Group and each of its’ affiliated facilities identified at the top of the first page of this application.

I have reviewed the information contained herein, and represent that it is factually true, accurate and complete. I understand that The Tanglewood 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 Designated Representative upon The Tanglewood Group’s admission of the Resident pursuant to this Admission Application, the terms and provisions of which are hereby agreed to.
Date
MM slash DD slash YYYY
"Resident"*
First Last
"Designated Representative"*
First Last
Signature
Name
This field is for validation purposes and should be left unchanged.

Call Tanglewood Group Today: 716-483-2876 or Schedule A Visit!

Residential Application

Step 1 of 7

I. Personal Data

II. Financial Data

Cash Assets

Real Estate

Securities

Life Insurance

Other Income

Burial

Liabilities

Divesting

Trusts

Person Assisting With Finances

Council

III. Statistical Data

IV. Social Data

V. Mental Health Data

VI. Other

Representations, Warranties and Indemnification Agreement

First & Last Name	Relationship	Address	City, State, Zip	Phone

Call Tanglewood Group Today: 716-483-2876 or Schedule A Visit!

Admission Application

Residential Application

Step 1 of 7

I. Personal Data

II. Financial Data

Cash Assets

Real Estate

Securities

Life Insurance

Other Income

Burial

Liabilities

Divesting

Trusts

Person Assisting With Finances

Council

III. Statistical Data

IV. Social Data

V. Mental Health Data

VI. Other

Representations, Warranties and Indemnification Agreement

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