You can expedite the application process by filling out this form, printing and signing the contract on the next page and then faxing or mailing the contract with a copy of your state license to us.

 

If you have more than one facility, please fill out once for EACH facility. We apologize for any inconvenience, but this will ensure we have good information to share with prospective clients.

Please fill out completely

Facility Information
Facility Name:
Street Address:
City:
State:
Zip Code:
Major Cross Streets:
Current Vacancies:
County
Facility Tel (with area code)
Website Address:
Email Address:
Licensing Information
State License #
Licensee Name
Licensed BedsTotal # of Beds
 # of NonAmbulatory Beds
Owner Information
 Nameplease add Mr. or Ms.
Street Address
City
Zip Code
Tel (with area code)
Fax (with area code)
Contact and Billing Information
 Contact for Referrals
Tel for Clients to call
Secondary Tel for Clients to call
Fax # for Referrals
Administratorplease add Mr. or Ms.
Send Billing to?Facility Address or Owner Address
Send Referrals to?Facility Address or Owner Address
Experience and Rates
Professional Licenses held by staff(RN, LVN, etc)
Priv Rm Starting $
Shd Rm Starting $
Hospice Waiver?Yes or No
If yes, rate per day $
Respite Care?Yes or No
If yes, rate per day $
Will you accept SSI as total payment?Yes or No
Additional Room Rate Info?
Languages Spoken by your staff: (check all that apply)
Albanian
American Sign Language
Arabic
Armenian
Austrian
Bulgarian
Burmese
Cantonese
Chinese
Croatian
Dutch
Farsi
Fijian
French
German
Greek
Hebrew
Hindi
Hungarian
Ilocano
Indian
Indonesian
Italian
Japanese
Korean
Lebanese
Lithuanian
Malay
Mandarin
Persian
Polish
Portuguese
Russian
Samoan
Serbian
Spanish
Swedish
Tagalog
Taiwanese
Ukranian
Urdu
Yiddish
Yugoslavian
Services and Care

Bathing

Dressing

Medication Supervision

Toileting

Feeding

Bladder Incontinency Care

Bowel Incontinency Care

Pool/Spa

Types of Elderly Residents your facility will accept

Uses Walker

Wheelchair Dependent

Needs Help Transferring to bed or Wheelchair

 

Check these only if you have an RN on staff and are willing to provide this type of care:

Resident with Colostomy

Resident with Catheter

Insulin Diabetic

Oxygen Use

What gender resident do you prefer?

MaleFemaleBoth

Will you accept pets?

Yes No Negotiable

Alzheimer's and Dementia Care
Do you accept residents who need assistance with all daily living activities?
Senile/Alzheimer's patients that will try to escape or wander off if not monitored closely
Do you have alarms on the doors and windows?
Is your property fenced?
If Yes, then explain your security system
Can you accept someone who is not cooperative much of the time and may be verbally abusive?
Can you accept someone who has a history of combative behavior (striking out)?
Do you have night staff awake and on duty to assist confused/frail residents who are up every night?
Are you a dedicated Alzheimer's facility (Your Facility does not accept mentally alert residents)?

Please summarize your experience and training in caring for the elderly along with any other information about your facility and care program:

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