Create an Account - Increase your productivity, customize your experience, and engage in information you care about.
Out of County Applicants: If you do not meet the residency requirement (currently living in Ozaukee County for at least 1 year), indicate the name and address of an immediate relative who does meet the residency requirement:
Please list all assets: Add together multiple Accounts
I agree to be responsible and pay for all sums due and owing Lasata Care Center upon receipt of bill. In the event that I am entitled to benefits from Medicare and Medicaid, such benefits are assigned to Lastata Care Center for application on my bill under terms as are required by the programs. In the event that I am entitled to benefits from my insurance policy, such benefits are assigned to Lasata Care Center for applicat8ion on my bill. I am aware that charges for room and board, nursing care, drugs, and nursing supplies, are made monthly and are for services received in the prior month. I agree to be responsible and pay for all sums not covered by these assignments.
If accepted for admission by Lasata Care Center, I agree not to make any inappropriate dispositions (divestment) of assets, which would impair my ability to pay for my care.
I certify that the statements contained in this application are true to the best of my knowledge. I understand that any false statements or willful misrepresentation shall be cause for rejection of my application and may be grounds for dismissal from Lasata Care Center, if admitted.
This is an application of voluntary admission and can legally be signed by applicant or court appointed legal guardian or ACTIVATED Power of Attorney for Health Care only.
This field is not part of the form submission.
* indicates a required field