Application for Admission

Application for Admission
TO UNITED METHODIST MEMORIAL HOME COMMUNITIES
Website: www.LifeAtHeritage.org

(Applicants are considered for admission without regard to race, color, sex, religion, national origin, disability, marital or veteran status consistent with all applicable federal and state requirements regarding non-discrimination.)

Each of the locations below are United Methodist Memorial Home (hereinafter “Heritage”) communities or facilities.
Heritage Pointe of Warren
801 Huntington Ave.
Warren, IN 46792
Phone: (260) 375-2201
Fax: (260) 375-3327
Heritage Pointe of Huntington
1180W 500N
Huntington, IN 46750
Phone: (260) 355-2750
Fax: (260) 355-2759
Heritage Pointe of Fort Wayne
5250 Heritage Parkway
Fort Wayne, IN 46835
Phone: (260) 209-6279
Fax: (260) 206-6301
Please note that after submitting this form, you will be asked at a later time to provide your Social Security number and Medicaid number. An applicant on Indiana Medicaid must furnish a copy of his/her Indiana Medicaid card in advance of admission.
Please check the box of the location(s) to which you are applying.*
- Heritage Pointe of Warren
- Heritage Pointe of Huntington
- Heritage Pointe of Fort Wayne
(When complete, your application will be submitted to the Admissions Department at each location you selected.)
How did you hear about us?*
- Television
- Newspaper
- Internet
- Friend/Family
What level of care are you applying for?*
- Villa (Fort Wayne and Warren only)
- Towne Home (Warren only)
- Independent Living
- Rehab
- Assisted Living
- Healthcare
- Memory Care
Applicant Data:
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Age at Application*
Current Address*
Street Address City State ZIP Code
Length of time at current location*
Phone*
Email*
Birth Place:*
County City State
Marital Status*
- Single
- Married
- Widowed
- Divorced
Date Married*
MM slash DD slash YYYY
Place Married*
Name of Spouse*
First Last
If spouse is deceased, date and place of death*
Church Membership
Denomination
Level of Education*
Occupation for Most of Life*
Are You a Veteran?*
- Yes
- No
Branch*
Preferred Funeral Home*
Funeral Home Phone #*
Funeral Home Address*
City State ZIP Code
Prepaid Burial?*
- Yes
- No
Burial Site
Have you ever been convicted of a felony?*
- Yes
- No
(felony convictions may be relevant, but may not automatically disqualify applicants for admission)
Please explain*
Do you currently have someone designated as your Power of Attorney, Healthcare Representative or Guardian?*
- Yes
- No
Name of Power of Attorney/Healthcare Representative/Guardian*
First Last
How will you provide documents designating or appointing the representative?*
- Upload the document digitally with this form
- I will provide a paper copy prior to admission
Please upload a signed copy of documents designating or appointing the representative.*
Max. file size: 50 MB.
Person(s) to contact in an emergency:
Contact #1 - Name*
First Last
Relationship*
Address*
Street Address City State ZIP Code
Email*
Email Address Type of Address (Personal, work, etc)
Phone*
Phone Number Type of Number (Home, Work, Cell, etc)
Do you have an additional contact to add?*
- No
- Yes
Contact #2 - Name*
First Last
Relationship*
Address*
Street Address City State ZIP Code
Email*
Email Address Type of Address (Personal, work, etc)
Phone*
Phone Number Type of Number (Home, Work, Cell, etc)

Resources and Verification Checklist.
Please provide a complete and accurate list of ALL your assets, property, and income from any source as of the date of application. This information must be provided at the time the admission application is submitted to Heritage, or within three days if an emergency-admit.
Assets
Real Estate
Value of Real Estate*
Additional Real Estate
Value of Additional Real Estate*
Cash/Checking/Savings
Value of Cash/Checking/Savings*
Statement Date*
MM slash DD slash YYYY
Investments (Annuities/Bonds/CDs/IRAs/Stocks)
Value of Investments*
Statement Date
MM slash DD slash YYYY
Other Assets
Value of Other Assets*
Statement Date
MM slash DD slash YYYY
Insurance
Health
Value of Health Insurance*
Statement Date
MM slash DD slash YYYY
Life
Value of Life Insurance*
Statement Date
MM slash DD slash YYYY
Long-Term Care (provide specifics of policy)
Value of Long Term Care*
Statement Date
MM slash DD slash YYYY
Income
Monthly Social Security
Amount of Income*
Statement Date
MM slash DD slash YYYY
Monthly Pension(s)
Amount of Monthly Pensions*
Statement Date
MM slash DD slash YYYY
Other Income
Amount of Other Income*
Statement Date
MM slash DD slash YYYY
Obligations
Mortgage
Amount of Mortgage Debt*
Statement Date
MM slash DD slash YYYY
Other Debts
Amount of Other Debts*
Statement Date
MM slash DD slash YYYY
Indiana Medicaid.
Are you currently on Indiana Medicaid?*
- Yes
- No
(If yes, then you will need to provide your Medicaid number and furnish a copy of your Indiana Medicaid card in advance of admission.)
Signature and Certification.
I certify that all of the above information is accurate and complete and that I have received a copy of the Heritage Admission Agreement which is incorporated herein by reference.
SIGNATURE OF APPLICANT TO APPLICATION:*
Consent
I accept this as my signature.
Date*
MM slash DD slash YYYY
SIGNATURE OF REPRESENTATIVE FOR APPLICANT:*
Consent
I accept this as my signature.
Date*
MM slash DD slash YYYY
Type of Representative*
- POA
- GUARDIANSHIP

ADMISSION AGREEMENT
UNITED METHODIST MEMORIAL HOME COMMUNITIES
801 HUNTINGTON AVENUE, P.O. BOX 326
WARREN, IN 46792

I – Heritage Service Limitations

Heritage Communities will disclose and provide to residents or potential residents, prior to time of admission, notice of special characteristics or service limitations of the facility. Examples of service limitations include, but are not limited to: ventilator patients, tracheostomies, sex offenders, actively suicidal residents, and residents requiring 1:1 care services. 1:1 care services are not included in any contracts or agreements nor is it provided by Heritage Pointe Communities. Alternate living options will be discussed for residents needing care consistent with 1:1 for their safety or the safety of others for a period greater than 24-48 hours. Alternate placement may include the transfer or discharge of your loved one to another facility including, but not limited to, inpatient psychiatric care, behavioral unit, or a long term care facility that is able to meet the needs of the resident.

II - Heritage Resident Charges and Fees
Upon admission, the following provisions shall apply to Heritage residents:

1. Prior to or on the date of admission, new residents entering Heritage residential or assisted living facilities will pay a fee of $3,000, and those new residents entering healthcare will pay a fee of $5,000. These amounts will be credited to the resident’s room and board account. In the event a resident withdraws from Heritage’s facilities, or is deceased, any portion of that fee in excess of room and board expenses incurred will be refunded by Heritage.

2. Residents who are on Indiana Medicaid will be required to provide Heritage with a copy of their Indiana Medicaid card in advance of their admission. In addition, residents will be required to pay their monthly charges and/or liability amount prior to, or on the day of admission, and each month thereafter.

3. A finance fee of 1.5% compounded monthly will be charged to resident account balances not paid by the end of each calendar month. Heritage shall be entitled to recover any collection costs and/or attorney fees incurred by Heritage in recouping those balances and fees.

Applicant authorizes the following contact person for matters relating to account(s) and service(s) at Heritage:
Billing Contact person*
First Last
Relationship*
Email Address*
Phone*
Phone Number Type of Number (Home, Work, Cell, etc)
Mailing Address*
Street Address Address Line 2 City State ZIP Code
III - Heritage Resident Responsibilities.
1. Applicants admitted to residency in any Heritage Community must:
2. Applicants becoming residents in a Heritage multifamily residential building must:
3. Residents understand that Heritage Communities strives to create and maintain an accommodating, relaxed, congenial and constructive living environment for Community residents within a framework of faith. In reaching for that objective, residents must reasonably comply with written boundaries of behavior that are established from time to time and communicated to involved residents by action of Heritage’s Board of Trustees. These written boundaries of behavior may have broad application or be situational or individually specific. At the reasonable discretion of Heritage, potential consequences of noncompliance with resident’s responsibilities may include but need not be limited to relocation of a noncompliant resident within Heritage facilities; or if no such better situation exists, then the equitable termination of the noncompliant resident’s residency in Heritage facilities.
IV - Approval by Board of Trustees Required
This Admission Agreement is to be signed by Applicant and submitted, with other documentation, for approval by the Heritage Board of Trustees. If approval is given, Applicant is not obligated to pay Heritage anything, nor does it create a right or obligation of Applicant to enter into residency in any Heritage facility. Applicant’s admission as a resident in a Heritage facility, and Applicant’s obligations hereunder, shall be effective only after Board approval and then only after all of the Heritage Residency Agreements specified below are fully executed by all parties and in force.

V - Heritage Residency Agreements
Important – Read Carefully. Applicant is encouraged to timely address questions and concerns he/she has related to any of the Heritage Residency Agreements (defined below) with a Heritage Admissions coordinator and Applicant’s trusted personal advisor(s) prior to signing and contracting with Heritage. Upon admission, the following agreements and contracts will establish and control the rights and obligations of Heritage and its residents relating to or arising out of residency in a Heritage facility or care or services rendered during any residency, and be binding upon their respective successors in interest:
- Application for Admission; and
- Admission Agreement; and
- Any other contracts or agreements signed by Applicant relating to residency in a Heritage facility; and
- All writings referenced in or attached to any of the above.
All of the above agreements and contracts (“Heritage Residency Agreements”) are incorporated in this Agreement and together they constitute one entire and integrated agreement. Heritage Residency Agreements shall be interpreted under the laws of the State of Indiana, except its choice of law provisions.

To the extent that any provision(s) of any agreement or contract between Applicant and Heritage is determined by a competent authority to be invalid, illegal, or unenforceable for any reason, that provision or part-provision shall, only to the extent required, be deemed to be deleted, and the remaining contractual provisions shall continue to be fully effective and binding to the full extent allowed by law.

VI - Acknowledgement and Signature:
I acknowledge that I have read and understand the above Admission Agreement. In the event of my admission to Heritage residency, I acknowledge being contractually obligated as a resident to comply with the terms of the Heritage Residency Agreements and to act responsibly as a part of the Heritage Community family. Incomplete and/or incorrect information provided to Heritage in the Application for Admission is grounds for denial of admission or, if admission is granted prior to all of the circumstances being known, termination of residency at the reasonable election of Heritage.
SIGNATURE OF APPLICANT TO APPLICATION:*
Consent
I accept this as my signature.
I accept this as my signature.
Date*
MM slash DD slash YYYY
SIGNATURE OF REPRESENTATIVE FOR APPLICANT:*
Consent
I accept this as my signature.
I accept this as my signature.
Date*
MM slash DD slash YYYY
Type of Representative*
- POA
- GUARDIANSHIP
Email
This field is for validation purposes and should be left unchanged.

Email Address	Type of Address (Personal, work, etc)

Phone Number	Type of Number (Home, Work, Cell, etc)

Email Address	Type of Address (Personal, work, etc)

Phone Number	Type of Number (Home, Work, Cell, etc)

Application for Admission

Applicant Data:

Person(s) to contact in an emergency:

Resources and Verification Checklist.

Assets

Insurance

Income

Obligations

Indiana Medicaid.

Signature and Certification.