ADMISSIONS - TABLE OF CONTENTS

ADMISSIONS POLICY and PROCEDURE..............………………………………......05-02-001

APPLICATION FOR ADMISSION……………………………………………………..05-02-002

Instructions for Completing Application
Application for Admission – Personal Information - Part 1
Military Service Information – Part 2
Eligibility Requirements – Part 3
Health Care Information – Part 4
Insurance Information – Part 5
Advance Directive Information – Part 6
Emergency Contact Information – Part 7
Burial Arrangements – Part 8
Authorization for Disclosure of Protected Health Information – Part 9
Medical Information – Part 10
Patient Information – Part 11
Financial Information – Part 12
Affidavit Regarding Income Tax Return – Part 13
Financial Release Request – Part 14
Durable Power of Attorney (Medical/Financial) – Part 15
Certification – Part 16
Required Copies of Documents Checklist / Work-Sheet
Appendix A – New Jersey Administrative Code (N.J.A.C.) 5A: 5 – Chapter 5
Appendix B – Notice of Information Practices-Resident’s Privacy Rights-HIPAA
Appendix C – Calculating Financial Costs – An Overview

NOTICE OF INFORMATION PRACTICES……………………………………………05-02-003

ACKNOWLEDGEMENT OF RESIDENTS’ PRIVACY RIGHTS…………………….05-02-004

VETERAN HOME RESIDENT HANDBOOK OF RULES & REGULATIONS……...05-02-005

RESPONSE CARD TO APPLICATION FOR ADMISSION….……………………….05-02-006

April 2004
Revised: March 2007