Admission Application

PART ONE

Person to contact in emergency

PART TWO

PART THREE - HEALTH HISTORY

PART FOUR - FINANCIAL STATEMENT/ DISCLOSURE

Monsignor Bojnowski Mano must be satisfied that all third-party payment mechanisms will be taken into consideration (i.e., Medicare / Medicaid, your resources). This is important for your protection and for the protection of Monsignor Bojnowski Manor. All financial information must be provided before an application is deemed complete. Should you desire, arrangements can be made for you to provide the financial information in person. Please give your total income for all sources.

Please give value of your total assets, including securities, bank accounts, real estate, personal property.

List debts, obligations, mortgages, etc. in dollar amounts that affect assets or income:

Your Bank(s)

If you anticipate or have applied for Medicaid (Title XIX), please answer the following questions:

Person responsible for payment of bills:

I understand that Monsignor Bojnowski Manor has a Provider Agreement with the State of Connecticut to provide services to Medicaid recipients pursuant to Title XIX of the Social Security Act and also participates in Medicare pursuant to Title XVII of the Social Security Act.

I have read and understand limitations on advance payments and Advance Payment Policy of Monsignor Bojnowski Manor.

Please note: the Manor is a Smoke-Free Facility. All information on this application will be held in confidence.