ADMISSIONS 05-02-002

DIVISION OF VETERANS HEALTHCARE SERVICES

POLICIES and PROCEDURES

APPLICATION FOR ADMISSION

Instructions for Completing 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

The Application for Admission can be viewed and printed out from the

New Jersey Department of Military and Veterans Affairs (DMAVA) web site located at:

http://www.state.nj.us/military/

Once you reach the DMAVA home page, click on

“New Jersey Veterans Memorial Homes – Application for Admission”

Revised: January 2007