Fillable Arizona State Veteran Home Application Packet (Arizona)

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Arizona State Veteran Home Application Packet (Arizona)

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Arizona State Veteran Home
Application Packet
Arizona State Veteran Home - Tucson
555 East Ajo Way, Tucson, AZ 85713
Arizona State Veteran Home - Phoenix
4141 North Silvestre Herrera Way, Phoenix, AZ 85012
Arizona State Veteran Home - Yuma
6051 East 34
th
Street, Yuma, AZ 85365
Admissions Hotline: 602-234-5678
1
© Arizona Department of Veterans’ Services. All rights reserved. www.dvs.az.gov (rev.2021-12-27.pia)
2
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
Frequently Asked Questions
Q: What are the eligibility requirements for admission?
A: Any Veteran (with the exception of those dishonorably discharged); Spouse of a Veteran; or
Gold Star Family Members
Question: What is the daily rate for private pay?
Answer (Phoenix): $165 per day / $4,950 per month
Answer (Tucson): $227 per day / $6,831 per month
Answer (Yuma): $280 per day / $8426 per month
Question: What insurance is taken?
Answer (Phoenix): All providers under Medicaid; additionally, some Medicare supplements are taken
(please contact in admissions specialist at (602-248-1594 to verify your eligibility).
Answer (Tucson): Medicare A and Mercy Care Advantage Plan are the only Medicare advantage plans
taken (please contact in admissions specialist at (520-638-2150 to verify your eligibility).
Answer (Yuma): TBD
Question: Are there any programs to assist with costs?
Answer: Medicaid, Arizona Long Term Care (ALTCS), non-service connected pension, and aid and
attendance, if eligible.
Question: Are there any cost breaks for service-connected disabled veterans?
Answer: Yes, the VA will pay for the Veteran if they have a 70% service-connected disability rating or
higher.
***An ADVS Veteran Benefits Counselor (VBC) can assist with filing a VA Disability/
compensation claim, please call (602)535-1215 to speak with a VBC***
Question: What is the capacity of the homes and what is the occupancy breakdown of the
rooms?
Answer (Phoenix): The max occupancy is 200 beds and there are 8 single rooms and 192 semi private
double occupancy rooms.
Answer (Tucson): The max occupancy is 120 beds, all of which are private rooms.
Answer (Yuma): The max occupancy is 80 beds, all of which are private rooms.
Recreation
Question: Are there recreation activities available?
Answer: Yes, our Recreation Department plays a vital role in the Veteran’s care. Services from this
department make available a therapeutic approach focusing on mind, body, and spirit, bringing balance
to one’s life. These services are incorporated in the plan of care.
Care Plans and Safety
Question: What is the visitation policy at the homes?
Answer: There are no defined visiting hours, however, we ask you to consider other residents who may
be sleeping if visiting during unusual times.
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
3
Question: What care options are available?
Answer: Arizona State Veteran Homes are long-term skilled nursing facilities that provide 24-hour
care for our residents. Additionally, every home has a professional staff that consists of CNA, LPN,
Nursing, Resident Physician, Physical Therapy and Dietary. Also, each home is equipped with a
Memory Care Unit, which is available to cognitive impaired Veterans at high risk of elopement.
Question: How is my level of care determined?
Answer: Upon move-in, our nurses and care team will assess your current health and review your
medical history to see how we can best meet your needs. They will also discuss your preferences as
well as your normal routines to develop a care plan that’s tailor made for you. This Individualized Service
Plan (ISP) details your care plan and is regularly updated to meet your evolving needs.
Question: Is Short-Term rehabilitation available?
Answer: Yes, If the applicant needs short-term rehabilitation, they must have traditional Medicare or a
service-connected disability of 70% or higher.
Question: Do residents still have access to medical care outside of the facility?
Answer: Yes.
Question: Is transportation provided for medical appointments?
Answer: Yes.
Question: Is Therapy offered?
Answer: Yes, offers skilled therapy and therapy to our long-term care veterans. These services include
Physical Therapy, Occupational Therapy and Speech Therapy. Therapy services are provided by
therapists and assistants in a fun, fast paced gym, located in our facility. Our Veterans receive therapy
that is patient focused in a family-oriented environment. Our size allows us the opportunity to be
responsive and innovative and to provide very personalized care, utilizing a team approach. The
dedication and experience of our staff are key to our success.
Question: Is assistance offered to residents that have experienced falls in the past?
Answer: Yes, we develop an Individualized Care Plan (ISP) for each resident that details care needs
and preferences and addresses safety concerns. If falling is a concern, the ISP may include
interventions and special precautions to help address this issue that will be followed by our Designated
Care Managers.
Question: Do you have a medication management program?
Answer: Yes, our homes have a medication management program, which may be added to an
Individualized Service Plan (ISP) and varies based on regulation. Residents participating in the
medication program may choose their own pharmacy or use the home’s preferred pharmacy provider in
that region. If a resident prefers to use an alternate pharmacy, the resident and pharmacy must comply
with certain requirements. Additionally, residents may be assessed to self-administer medications.
Question: Is social services available at the homes?
Answer: Yes
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
4
Mission Statement: The mission of the Arizona State Veteran Homes is to provide professional
skilled nursing and rehabilitative care for the geriatric and chronically ill Veteran and
dependent/surviving spouses throughout the State of Arizona. Our goal is for each veteran to attain or
maintain his or her highest practicable physical, mental and psychosocial well-being.
Thank you for your interest in applying for residency to one of our Arizona State Veteran Homes.
This application packet includes the complete package that is required to be completed for
admission to one of the Arizona State Veteran Homes.
TABLE OF CONTENTS
Description
Page
FAQs
2
Application Instructions
4
Admission Qualification
5
Document Checklist
5
Section A – General Information
6
Section B – Resident/Patient Health Information
11
Section C – Physician’s Medical Certificate (Completed by Physician)
13
Section D – Functional Assessment (Completed by Applicant or Representative)
16
APPLICATION INSTRUCTIONS
If you need assistance in completing the application or if you have any questions, see page 10 in
Section A of this application.
Follow the instructions below to begin the application process. If a spouse or domestic partner is
also applying, please submit a separate application. In order to expedite the admissions process
please take the following steps:
1. Complete Section A and Section B of this application.
2. Provide Section C to your primary care physician for completion. Contact your
physician as soon as possible for an exam to complete the section in its entirety.
Section C is only valid for 6 months and depending on your admission date it may
be necessary to complete Section C again to ensure it is valid.
3. To ensure care needs are able to be met for all admissions to the home, current
medical records must be reviewed.
4. Include copies of current Advanced Directives, Power of Attorney, Court appointed
Conservatorship or Guardianship, and Living Will.
5. Completed application packages must include all required documents that are
included on the “Document Checklist” found on page 6.
6. Submit completed applications via fax, email or mail to the Arizona State Veteran
Home of your choice. Contact information is on page 10.
We look forward to working with you and ask that you please call the admissions team at the
Arizona State Veteran Home if you should have questions while completing this application.
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
5
Admission Qualifications
To be admitted to an Arizona State Veteran Home the applicant must be a Veteran, a Veteran
Spouse, a surviving spouse, or an immediate Gold Star family member and the following
requirements must be met:
Application
A.
An applicant or legal representative shall apply for admission to an ASVH by submitting a
completed ASVH application to the admissions coordinator. If both a Veteran and the
Veteran’s spouse are applying for admission, both shall file separate applications. An
application may be obtained from an ASVH or from the agency website at www.azdvs.gov
B.
In addition to the ASVH application required under subsection (A), an applicant or legal
representative shall submit the following:
1. Information regarding the applicant's ability to participate in daily living activities and the
applicant's psychosocial behavior. The information may be provided through either of the
following:
a. A functional questionnaire form provided by ASVH that is completed by the applicant or
family member, or
b.
The equivalent medical information provided by a health care provider;
2.
A completed applicant's financial information statement on a form provided by ASVH;
3. A completed physician's statement by the applicant's physician on a form provided by
ASVH or equivalent medical information;
4.
A copy of the veteran's discharge document from the United States military, a certified
copy of the separation or discharge document issued by the National Personnel
Records Center, or a Statement of Service issued by the VA Regional Office;
5. If requested by the director of nursing, a copy of medical records that assist in determining
the level of care required by the applicant. Medical records may include physician's
records, nurses' notes, test results, and medication records; and
6. Evidence of freedom from infectious pulmonary tuberculosis.
C.
Evidence of treatment at a VA Medical Center will satisfy the requirement in (8) (4) of
this se
ction.
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
6
DOCUMENT CHECKLIST
In order to assist our applicants, we have provided the following document checklist. Please
ensure all required documents are available or admission could potentially be delayed.
•
IDENTIFICATION
o
DD Form 214: Certificate of Discharge
o
Birth Certificate
o
Driver’s License/Identification Card (State Issued)
o
Social Security Card
•
MEDICAL INSURANCE
o
Arizona Health Care Cost Containment System (AHCCCS) Card
o
Medicare Card
o
VA Medical Card
o
Dental or Other Insurance Card
•
LEGAL/OFFICIAL PAPERS
o
Advanced Directives
o
Power of Attorney and/or Durable Power of Attorney
o
Marriage Certificate (if currently married)
o
Final Divorce Decree (if applicable)
o
Pre-Arranged Burial Plan
o
Will or Trust
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
7
SECTION A
GENERAL INFORMATION
Please let us know how you heard about us:
PERSONAL INFORMATION
1. Applicant Name:
Last First Middle Maiden
2. Current Residence:
Address City State Zip
3. Mailing Address (if different):
Address City State Zip
( )
County Telephone
4. Social Security Number: Sex: Male Female
5. Date of Birth: / / Birthplace:
City State County
6. Ethnicity: White Hispanic Black American Indian/Alaska Native
Asian/Pacific Islander Other (specify):
7. Religious Preference:
8. Marital Status: Married Widowed Divorced Separated Never Married
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
8
9. Spouse’s Name:
Last First Middle Maiden
10. Work History:
Previous occupation Kind of business
11. Responsible Party:
Full Name Relationship
( )
Phone Number Address City State Zip
_ _ _ _
Email address Work phone number
12. Emergency Contact 1:
Full name Relationship Phone number
Address City State Zip
Emergency Contact 2: __________________________________________________________________
Full Name Relationship Phone number
Address City State Zip
13. Date of:
_____/_____/______
Enlistment
Discharge
Era
14.
Branch:
Army
Navy
Marines
U.S. Coast Guard
Air Force
Merchant Marine
15.
Check all that apply: WACS
WAAF
WMC
SPARS
POW
Nurse Corps
16.
Does applicant have a service-related disability? Yes No
17.
If yes, what is the percentage?
18.
Applicant’s Armed Services Serial Number
19.
Applicant’s Dept. of Veterans Affairs Claim or File Number
_____/_____/______
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
9
20.
Applicant represented by a Veteran Service Organization? Yes No
POA?
21. Insurance:
22. Has applicant signed up for Medicare?
23. If yes: Part A Part B QMB
Yes No
SLMB
Medicare Number
24. Is applicant currently on AHCCCS? Yes No
If yes, plan and number:
25. Is applicant currently on ALTCS? Yes No PID number
Name of ALTCS Case Manager:
26. Does applicant have other insurance? Yes No
If yes, please provide the following: Name of insurance:
Policy number:
Address of company:
Phone number of company: ( )
27. Does applicant have nursing home insurance? No If yes, attach a copy of the policy
28. Service organization membership (VFW, Elks, etc.):
29. Advance Directives:
30. Does applicant have a: (Check if yes, attach a copy of the documentation)
Power of attorney Court appointed guardianship or conservatorship Living will
Health care power of attorney
31. Name of agent: Relationship:
Address City State Zip
( )
Telephone number
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
10
32. Provide name, address and telephone number of preferred Funeral Director:
Name: Phone number: ( )
Address City State Zip
33. Provide name, address and telephone number of preferred cemetery:
Name: Phone number: ( )
Address City State Zip
Arizona State Veteran Home Preference
The Arizona Department of Veterans’ Services operates 2 State Veteran Home. Select your
preference for the Home(s) you are applying to. Mark “1” for your first choice, “2” for your
second choice, and so on. If you are not interested in a specific Home, mark an “X” next to “I
do not wish to apply for this location.” In the event the location you have selected has no
availability you will be informed and given the option to automatically be considered for your
subsequent preferences or you may elect to wait for your desired location to have availability.
Your completed application and required records should be submitted only to your first choice.
If you decide to revise your order of priority simply contact the Home and request they forward
your application and required information to your new preferred Home.
Location
Order of
Preference
Check if Not Interested
ASVH-Phoenix
#
Not Interested in this location
ASVH-Tucson
#
Not Interested in this location
ASVH-Yuma
#
Not Interested in this location
Application Assistance and Submission
If you need assistance filling out the application or have any questions, contact any of the locations
below. Please submit your completed application via fax, email or mail to your Home of choice.
Location
Telephone
Fax Number
Email Address
ASVH-Phoenix
602-234-5678
602-263-1826
asvhphx-admissions@azdvs.gov
ASVH-Tucson
602-234-5678
602-773-0935
asvhtuc-admissions@azdvs.gov
ASVH-Yuma
602-234-5678
928-569-5712
asvhyuma-admissions@azdvs.gov
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
11
Applicant/Legal Representative: Read the following and Sign:
I further declare that I am a legal resident of the State of Arizona. I will submit a copy of
Honorable or General discharge documentation from the military service of the United
States. I will inform the ASVH of any and all changes in my income and/or assets. I will
obey the rules and regulations prescribed for the ASVH.
I hereby authorize the ASVH to obtain all medical records from my physician, hospital,
clinic or nursing home pertaining to my potential admission to the facility. These records
may include, but are not limited to, diagnostic/laboratory results, consultant and progress
notes/reports, assessment tools/reports, readmission screening documents, documentation
for Medicare benefits and any other items specified by the ASVH.
Signature of Applicant or Legal Representative Date
Admission shall be in accordance with Title VI of the Civil Rights Act of 1964 as amended;
Section 504 Rehabilitation Act of 1973 as amended; the Age Discrimination Act of 1975; the
Age Discrimination Act of 1967; the American’s with Disabilities Act of 1990; and Arizona
Administrative Code Title 4 Charter 40.
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
12
SECTION B
The following information is required to process your application for admission to the
Arizona State Veteran Home. If this information is incomplete, it will delay consideration of your
application. If questions are not applicable, please indicate with the abbreviation “N/A”.
Information submitted is subject to verification. The Arizona State Veteran Home reserves the
right to request verification of any funds received by copies of award forms or award letters.
APPLICANT’S NAME DATE
APPLICANT’S SOCIAL SECURITY #
SPOUSE’S SOCIAL SECURITY #
A. MONTHLY INCOME VETERAN SPOUSE
Social Security Benefits
U.S. Civil Service benefits (annuity
number)
U.S. Railroad retirement (number)
Military Retirement
Military Retirement
V.A. Awards (type)
State Retirement Company
Retirement
Private Retirement
Black Lung
Benefit
SSI/Public Assistance
Total Wages Total
Dividends Total Interest
Other (specify source):
Total Monthly Income
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
13
B. EXPENDITURES
Medicare B Premium (per month)
ALTCS Share of Cost (per month)
C. ONE TIME INCOME IN THE PAST 12 MONTHS
Type:
Type:
Amount:
Amount:
D. NET WORTH (Excluding Home and Auto)
Cash Bank Account Savings
CD’s Millers Trust Revocable Trust
NET WORTH TOTALS
E. MEDICAL EXPENSES NOT REIMBURSED LAST YEAR
Signing below certifies that the above information is complete and correct. Authorization is given to
verify any information provided herein.
Signature Date Relationship
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
13
SECTION C
PHYSICIAN’S CERTIFICATION
The following information is to be completed and signed by the applicant’s physician. This
certification is valid for 6 months from the date of completion. All information must be current and
complete to avoid delays in processing. Please attach a copy of the patient’s current (completed
within the last 3 months) History and Physical (H&P) as well as a current TB test. Medications must
be listed on this form or supplemented with a typed medication list that is signed by the physician.
1. Name of Applicant:
2. Date of Birth:
3. Is this person capable of caring for him/herself? Yes No
4. Patients current diagnosis:
5. Applicant’s current medications:
Medication
Dose
Frequency (x per day)
DX for Medication
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
14
1. Diet and Diet Consistency:
2. Activity Orders/Limitations:
3. Are special treatments or therapies required for this person? Yes No
4. Could this person be considered a danger to self or others? Yes No
If yes, please explain:
5. Have they had a Mantoux TB skin test done in the past 6 months?
If yes, please attach a copy of the results
Yes No
6. Has this person had Pneumovax 23? Yes No Date:
7. Has this person had Pneumovax 14? Yes No Date:
8. Allergies?
9.
10. Both doses of the COVID-19 vaccine? Yes No
11. If only one dose, which one and when?
12. Please print or type the following:
( )
Physicians name Telephone number
Address City State Zip
Please return this statement to the Arizona State Veteran Home with a copy of the patient's
history, physical and TB test results.
Physicians signature Date
Is it your opinion that this applicant is in need of 24-hour nursing care?
Yes
No
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
15
SECTION D
FUNCTIONAL ASSESSMENT
For each area of functioning listed below, please describe to the best of your ability the amount and
type of assistance the applicant currently requires.
BATHING
Does the applicant take a: Shower Tub bath Sponge bath
How often does the applicant bathe?
How much assistance is required?
DRESSING
How much assistance does the applicant receive in dressing (including selecting and getting clothes
from the closet, putting on undergarments and using fasteners)?
TOILETING
Does the applicant require assistance with toileting (including getting to and from the bathroom,
cleaning self after elimination and arranging clothes)?
If yes, how much assistance is needed?
Does the applicant have a catheter?
Yes
No
If yes, what type?
Does the applicant have a colostomy?
Yes
No
Is the applicant able to control urination? Bowel movements?
If no, how often do “accidents” occur?
MOBILITY
Does the applicant walk (list assistive devices used) or do they use a wheelchair?
Does the applicant need assistance getting out of bed or a chair? Yes No
If yes, how much assistance is needed?
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
16
EATING
Does the applicant feed themselves or require assistance?
Does the applicant use adaptive equipment while eating (plate guard, special spoon, etc…)?
Yes No If yes, describe the type and frequency
Is the applicant on a special diet?
How would you describe the applicant’s appetite?
Height Weight
PROSTHESES
Does the applicant have an arm or leg prosthesis?
Does the applicant wear dentures (upper and lower)?
Does the applicant use hearing aid(s)?
SKIN
Does the applicant presently have pressure sores (if yes, where are they and how long)?
Does the applicant have skin rashes?
Does the applicant experience swelling of the legs and/or feet?
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ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
17
ORIENTATION
Is the applicant alert and oriented or do they exhibit confusion? (If confused, is it ongoing,
often, or occasional?)
For individuals who are confused and disoriented:
Does the applicant attempt to wander?
If yes, how often?
Yes No
Is the applicant willing to return if given direction?
OTHER HEALTH CONSIDERATIONS
Does the applicant currently use physical or chemical restraints?
If yes, describe the type and frequency
Has the applicant been hospitalized or are they currently being treated for mental health problems?
If yes, describe the type and frequency
Does the applicant maintain active and satisfying relationships with family and friends?
ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION
18
© Arizona Department of Veterans’ Services. All rights reserved. www.dvs.az.gov (rev.2021-12-27.pia)
Does the applicant have a history of drug and/or alcohol abuse?
If yes, please describe:
Yes No
_
Is the applicant an active smoker? Yes No
If yes, are they considered safe? Yes No
Is the applicant currently receiving physical, occupational, speech, or respiratory therapy? If
yes, list the type of therapy, reason, and frequency the therapy is received:
ADDITIONAL INFORMATION:
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Arizona State Veteran Home Application Packet (Arizona)

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Completed 8 July 2022

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