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Personal Information
First Name
Last Name
Middle Name
Maiden Name
Likes to be called
SSN
Address1
City
State
Zip
Phone Number
Email Address
Date of Birth
Place of Birth
Marital Status
Gender
1. Male
1. Female
Religious Information
Church Affiliation
Address
City
State
Zip Code
Funeral Arrangements Information
Do you have a funeral Trust?
1. Yes
1. No
Funeral Home
Years of residency (as an adult) in Ozaukee County
Have you ever been to Lasata Care Center Before?
Have you been to another care facility?
Residency Information
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:
First Name
Last Name
Relationship
Address
City
State
Zip Code
Years in Ozaukee County
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Insuracne Information
Medicare Number
Title 19- Medical Assistance #
Supplemental Insurance
Supplemental Insurance ID#
Long Term Care Insurance
Long Term Care Insurance ID #
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Prescription Insurance
Company Name
Member ID
RxPCN
RxBin
RxGRP
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Medical Information
Primary Physician
Address
City
State
Zip Code
Phone Number
Dental Information
Dentist
Address
City
State
Code Zip
Phone Number
Other Medical Information
Hospital Preference
Pharmacy Preference
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Social History
Your profession or occupation before retiring
Were you in the military service?
1. Yes
1. No
If yes, which branch?
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Confidential Financial Information
This confidential information will be used in determining your ability to meet financial obligations. It is used solely by Lasata Care Campus.
Please list all assets: Add together multiple Accounts
Real Estate Estimated Market Value
Amount of Mortgage
Checking Accounts- Approximate Amount
Savings/Money Market Accounts- Approximate Amount
Certificate of Deposit- Approximate Amount
Stock and Bonds- Total Approximate Value
Total Assets
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Monthly Income
Social Security
Interest
Pension
Dividends
Annuities
Trust Income
Rental or Real Estate
Other Income
Total Monthly Income
Have you sold or given away any assets or property in thepast sixty (60) months?
1. Yes
1. No
If yes, please provide details including what, how much, to whom, and when below.
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Room Information
Room Applying For
1. Private
1. Semi Private
1. Either
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Emergency Contacts
First Name
Last Name
Relationship
Address1
City
State
Zip
Home Phone
Cell Phone
Other Phone
Email Address
First Name
Last Name
Relationship
Address1
City
State
Zip
Home Phone
Cell Phone
Other Phone
Email
First Name
Last Name
Relationship
Address1
City
State
Zip
Home Phone
Cell Phone
Other Phone
Email Address
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To Whom Should the Billing Statement be sent?
First Name
Last Name
Relationship
Address
City
State
Zip Code
Phone Number
Guarantee of Payment
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.
Do you wish to be on the active list or inactive list? If left blank, we will assume inactive placement.
1. Active
1. Inactive
By checking this to I agree to the terms included in this form.*
1. I Agree
Date
Date

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Application for Long-Term Stay at Lasata Care Center

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