VALLEY VIEW HOME APPLICATION FOR ADMISSION
Name of Applicant:______________________________________________ Date of Application:_______________ Admitted From:__________________ Dates:_______________________ Address:_________________________ Soc. Sec. No.:___________________ Medicare A #:___________________
Birthplace:____________________ Date of Birth:_____________________ Marital Status: Single Married Widow Widower Divorced Name of Husband or Wife:________________________________________ Previous Occupation:____________________________________________ Children: Name
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Brothers and Sisters: Name
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Name and address of my Doctor:___________________________________ Who are to be notified in case of emergency: (List two names) Name
_____________________________________________________________ _____________________________________________________________ Are you a Veteran?______________________________________________
Name and address of Church of which you are a member: Name
_____________________________________________________________ Name of Person who will handle your personal and financial affairs: Personal: _____________________ Financial: ___________________
How Account is to be Paid: Private Pay: Medicare: Medical Assistance:
Date of Application: _____________________________
Policy #'s: _________________________________________
Name of Company(s): ________________________________
Phone Numbers: ____________________________________
Preferred Mortuary: ________________________________________ Cemetery Lot: _______________________ Location: _____________ Power of Attorney ( if any) held by whom: _________________________ __________________________________________________________ Please send a copy of P.O.A. and Living Will to Valley View Home.
VALLEY VIEW HOME ADMISSION AGREEMENT NONDISCRIMINATION POLICY FOR ADMISSIONS
No applicant for or recipient of medical assistance may be excluded from participation in medical assistance or dental benefits in violation of the civil rights act of 1964, 42 USC 100, Et Seq., the age discrimination in employment act of 1967, the age discrimination act of 1975, S.504 of the rehabilitation act of 1973, as amended, and the department standards for equal opportunity in service delivery. Accordingly recipients may not be excluded, denied, or refused health care services on the grounds of race, color, gender, age, national origin, religion, handicap, sexual orientation, marital status, arrest record or diagnosis. This facility will conduct an internal review of appropriateness of placement for individuals with a diagnosis of MR, DD or MI.Approval of a Level II for these individuals will not be the only qualifier for admit. The facility may require a medical guardianship or at a minimum, a durable POA as terms for admission. The primary purpose and scope of the facility's programming is not designed to serve or meet the special needs of individuals with MR / DD requiring a custodial / immediate level of care. A determination for appropriateness of placement will be based on functional / acuity levels and the need for specialized skilled nursing services. (Revised 8/10/98) A. SERVICES AND CHARGES
The Facility agrees to furnish the Resident with the following services
included in the daily rate: room, board, required nursing care, personal
care, basic equipment, and supplies, housekeeping services, social
services, and other services required by law, at a cost of _________/day
Large Private Room, ____________/day Small Private Room.
The Facility's daily rate does not include special or extra services
including but not limited to the following: personal clothing, special or
customized equipment and supplies, beauty and barber services,
therapies by licensed therapists, drugs and medications, oxygen,
laboratory fees (tests), physician, dental, podiatry, and psychiatric care.
The daily charge is incurred upon the date of admission and whenever a
room is reserved for or occupied by the Resident.
The facility will bill long term care insurances. We request that a copy of your
policy and claim forms be provided to the facility. You will receive a statement,
monthly, even though you are waiting for payment from the insurance company.
You are required to pay the charges billed to you every month. If the nursing
home is to be the recipient of the insurance company’s payment, we will make an
The Resident may require a change in care necessitating a change in charges. Such change in charges shall be made on basis of an assessment and notice, which will be given by the Facility as soon as reasonably possible. Changes in charges, due to cost of living increases will be communicated in writing to the Resident or responsible party at least thirty (30) days prior to the effective date of such change. Private Pay Residents will be charged the daily room rate to hold a room/bed while a Resident is hospitalized. Medicaid eligible residents will have their room/bed held and paid for by Medicaid during hospitalization for as long as there is an expectation of return to the facility. Residents on Medicaid will have up to 24 days for their bed to be held during therapeutic leaves (July 1 - June 30). If therapeutic leave exceeds 24 days, they may lose the bed unless other parties may pay the daily charge to hold the room.
In situations where conditions of billing for holding a bed are not met, providers must hold the bed and may not bill Medicaid for the bed hold day until all conditions of billing are met and may not bill the resident under any circumstances.
2. Medical Assistance
If the Resident is eligible for Medical Assistance, whether at the time of
admission or thereafter, the Resident and Spouse financially responsible
for Resident, if any, signing this Agreement, shall complete and file all
Medical Assistance application forms and shall notify the Facility's
Business Office promptly of any delay or difficulty in such application for
Medical Assistance. While an application for Medical Assistance is
pending or if for any reason the Facility cannot obtain payment under the
Medical Assistance program for lawful charges incurred on behalf of the
Resident, the Resident and Spouse financially responsible for Resident,
if any, signing this Agreement agree to pay all lawful charges for services
rendered by the Facility. If Medical Assistance pays the Facility for any
charges previously paid by the Resident and Spouse financially
responsible for resident, if any, signing this Agreement, the Facility will
refund those payments to the Resident and Spouse financially
responsible for Resident, if any, signing this Agreement.
If the Resident is a recipient of Medical Assistance, the Resident and
Spouse financially responsible for Resident, if any, signing this
Agreement shall pay to the Facility any insurance, social security, or
other benefits Resident is entitled to as directed by the Medical
If for any reason the Facility cannot obtain payment under the Medical
Assistance program for lawful charges incurred on behalf of the
Resident, the Resident and Spouse financially responsible for
Resident, if any, signing this Agreement agree to pay those lawful
If the Resident is eligible for Medicaid, the Facility shall provide a list
of the items and services included under the State plan and for which
the Resident may not be charged. A list of these items and services,
is attached and is incorporated herein by references. Medicaid Fraud
control Unit: Fraud & Recoveries Unit, 2401 Colonia Dr., P. O Box
Resident charges will not be imposed against the personal funds of a
resident for any item or service for which payment is made under
The Resident or person financially responsible for Resident, if any,
signing this Agreement will pay for all emergency transportation,
hospital admission expenses, and any special charges not included
in the daily charge incurred for the Resident.
The unused portion of the daily rate charges will be refunded after a
The Facility reserves the right to transfer or discharge a Resident for
1. The transfer or discharge is necessary for the Resident's welfare
and the Resident's needs cannot be met in the Facility.
2. The transfer or discharge is appropriate because the Resident's
health has improved sufficiently so the Resident no longer needs
3. The safety of individuals in the Facility is endangered.
4. The health of individuals in the Facility would otherwise be
5. The Resident has failed, after reasonable and appropriate notice,
to pay for (or to have paid under Medicare or Medicaid) a stay at
the Facility. The Facility shall notify the Resident at least 30 days
in advance of an involuntary transfer outside the Facility, except
As immediate transfer or discharge is required by Resident's urgent
medical needs, or the health and safety of individuals in the Facility
7. Residents may appeal the involuntary discharge or transfer to the
Office of Fair Hearings, 2401 Colonial Drive - 3rd Floor, P. O. Box
202953, Helena, MT 59620, (406)444-2470
Resident's Right to Refuse Transfers:
An individual has the right to refuse a transfer to another room within the
Facility, if the purpose of the transfer is to relocate;
1. A Resident of a SNF, from the distinct part of the Facility that is
SNF, to a part of the Facility that is not a SNF.
2. If a Resident of a NF from the distinct part of the Facility that is a
NF to a distinct part of the Facility that is a SNF.
3. A Resident's exercise of the right to refuse transfer, under paragraphs 1 & 2
of this section, does not affect his/her eligibility or entitlement to Medicaid benefits.
The Facility will make every effort to assign residents to the room of
their choice. However, due to constraints related to compatibility level
of care, sex, and payment source, this is not always possible. For these
reasons it may become necessary to move a Resident.
Personal clothing must be of washable nature. The facility will not
accept responsibility for removal of nonwashable garments from
circulation or damage to nonwashables that are delivered to facility
laundry. The facility will utilize a label press for identification of clothing.
AUTHORIZATIONS AND ACKNOWLEDGMENT 1. Physician Services
I authorize Dr. _____________ to be the physician in charge of
treating the Resident. In an emergency, or if the attending physician
does not provide service for the Resident as required by Federal and
State guidelines, the Facility is authorized to call another licensed
physician. The physician responsible for coordination of the Resident's
care may be contacted at this address and phone number:
2. Pharmacy Services
The pharmacy shall provide medications for each resident in accordance with
the medication delivery system utilized by the facility which is designed to
ensure safety, accuracy, and efficacy. The facilities system requires that
medications be dispensed and packaged into a “bubble or blister card” which
is size appropriate to the facilities secured medication cart. Any resident who
utilizes the VA pharmacy service will be exempt from this requirement. The
pharmacy chosen by the resident must have the capability to dispense and
package the medications in a manner that complies with the facilities
medication delivery system. Upon discontinuation of a medication, the
disposition of the medication shall be in accordance with Federal and State
I authorize that all prescriptions be filled by____________________________.
3. Dental Services
I authorize Dr. ______________ to be the dentist responsible for treating the Resident. In an emergency, or if the dentist does not provide service for the Resident as required by Federal and State guidelines, the Facility is authorized to call another dentist.
4. Vision Services
I authorize Dr. _______________ to be the eye doctor to handle my vision
care. In an emergency, or if my eye doctor is not able to provide the
service, I authorize the Facility to call another eye doctor.
5. Resident Funds Account
Valley View Home will handle Resident personal funds in the office.
Resident account funds are protected through a Surety Bond coverage.
Resident personal funds in excess of $50 will be kept in an interest
Financial records will be available through quarterly statements and on request
to the resident or responsible party. The SSI / Medicaid resource limit for one
We will notify the resident when the amount is $200 less than the resource limit. The appropriate resource limit must be maintained for continued program eligibility. Upon death of a Resident, the nursing home will convey
within 30 days the Resident's fund to the estate or responsible party.
The nursing facility or a person, other than a financial institution,
holding personal funds of a deceased nursing facility resident who
received Medicaid benefits at any time shall, within 30 days following
the resident's death, pay those funds to the Third Party Liability Unit, 2401
Colonial Dr. - 2nd Fl., P.O. Box 202953, Helena, MT 59620, (406) 444-4162.
A nursing facility may satisfy a debt owed by the deceased resident to
the facility from the deceased resident's personal funds that are held
by the nursing facility and that would have been payable to the facility
from the resident's funds. The facility shall pay the remaining funds to
the department as required by this section.
I do ____ do not ____ authorize the Facility to handle personal funds
for the above named Resident. All financial transactions done on
behalf of the Resident will be clearly documented in the business
office and records shall be available in accordance with regulations.
6. Room Type
I do ____ do not ____ want a large private room if available.
(Medicaid does not cover the additional charge for a large private room.)
In the event of a payment source change, (i.e. private pay to Medicaid),
a room change will be made only upon the request of the resident, family
I do ____ do not ____ wish to have my religious preference listed.
____________________ is the preferred affiliation revealed for
I do ____ do not ____ wish to have my name listed on the facility directory.
9. Consent for Treatment
I, __________________________, a Resident in Valley View Home,
hereby authorize Dr. __________________ (or whomever he/she may
designate for me in his/her absence) to administer such medical treatments or procedures as are necessary during my residence at
Valley View Home does not participate in experimental research.
EXHIBITS THAT ARE PART OF THIS AGREEMENT
Directives in case of "Cardiac Arrest"
I, the undersigned, hereby certify that I have carefully studied this agreement and the exhibits and understand it in detail and that I have answered correctly to the best of my knowledge and belief all questions herein contained. IN WITNESS WHEREOF, MY SIGNATURE THIS ____ day __________, 20____ ____________________________ __________________________
I, the undersigned, a representative of Valley View Home, do hereby certify that we accept this application and that the Home will provide, to the best of its ability, with the resources available, a comfortable Christian Home for said Resident.
NURSING FACILITY SERVICES INCLUDED IN THE DAILY RATE
The services and examples of services listed in this subsection are included in the rate determined by the department under ARM. 1.
All general nursing services including but not limited to administration
of oxygen and medications, handfeeding, incontinent care, tray
service, nursing rehabilitation services, enemas, and routine pressure
Services necessary to provide for residents in a manner and in an
environment that promotes maintenance or enhancement of each
Services required to attain or maintain the highest practicable physical,
mental, and psychosocial well-being of each medicaid recipient who
Items furnished routinely to all residents without charge, such as resident
gowns, water pitchers, basins, and bed pans.
Items routinely provided to residents including but not limited to:
Anti-bacterial/bacteriostatic solutions, including betadine,
hydrogen peroxide, 70% alcohol, merthiolate, zepherin
Hypodermic needles (disposable and non-disposable)
Medication - dispensing cups and envelopes
Ointments for general protective skin care
Laundry services whether provided by the facility or by a hired firm,
except for residents' personal clothing which is dry cleaned outside
Nonemergency routine transportation as defined in subsection (13).
"Patient contribution" means the total of all of a resident's income
from any source available to pay the cost of care, less the resident's
personal needs allowance. The patient contribution includes a
resident's incurment determined in accordance with ARM 37.40.331.
"Patient day" means a whole 24 hour period that a person is present
and receiving nursing facility services, regardless of the payment
source. Even though a person may not be present for a whole 24 hour
period on the day of admission or day of death, such day will be
considered a patient day. When department rules provide for the
reservation of a bed for a resident who takes a temporary leave from a
provider to be hospitalized or make a home visit, such whole 24 hour
periods of absence will be considered patient days.
"Provider" means any person, agency, corporation, partnership or
other entity that, under a written agreement with the department,
furnishes nursing facility services to medicaid recipients.
"Rate year" means a 12 month period beginning July 1. For example,
rate year 1993 means a period corresponding to state fiscal year 1992.
"Resident" means a person admitted to a nursing facility who has been
present in the facility for at least one 24 hour period.
"Total allowable remodeling costs" means those remodeling costs which
are supported by adequate documentation. The costs include, but are not
limited to, all costs of construction. These cost do not include costs of
moveable equipment, supplies, furniture, appliances or other similar
Personal hygiene items and services, including but not limited
Bathing items and services, including but not limited to towels,
Hair care and hygiene items, including but not limited to
Miscellaneous items and services, including but not limited to
cotton balls and swabs, deodorant, hospital gowns, sanitary
napkins and related supplies, and tissues
Skin care and hygiene items, including but not limited to bath
soap, moisturizing lotion, and disinfecting soaps or specialized
cleansing agents when indicated to treat special skin problems
Tooth and denture care items and services, including but not
limited to toothpaste, toothbrush, floss, denture cleaner and
Supplies necessary to maintain infection control, including
those required for isolation-type services
Over-the-counter drugs (or their equivalents), including but not limited
Acetaminophen (regular and extra-strength)
Suppositories for evacuation (dulcolax and glycerine)
Syringes (disposable or non-disposable hypodermic, insulin,
Items used by individual residents which are reusable and expected
to be available, including but not limited to:
Bedside equipment, including bedpans, urinals, emesis basins,
Blood pressure equipment, including stethoscope
Room (private or double occupancy as provided in
CHARGEABLE ITEMS FOR THOSE ON MEDICAL ASSISTANCE
The department will not pay a provider for any of the following items or services provided by a nursing facility to a resident. The provider may charge these items or services to the nursing facility resident:
Social events and entertainment outside the scope of the
Cosmetic and grooming items and services in excess of those
for which payment is made by medicare or medicaid
Personal comfort items, including tobacco products and
accessories, notions, novelties, and confections
Television, radio and private telephone rental
Less-than-effective drugs (exclusive of stock items)
Specially prepared or alternative food requested instead of food
The difference between the cost of items usually reimbursed under
the per diem rate and the cost of specific items or brands
requested by the resident which are different from that which the
facility routinely stocks or provides (e.g., special lotion, powder,
Services provided in private rooms will be reimbursed by the department at the same rate as services provided in a double occupancy room.
A provider must provide a medically necessary private room
at no additional charge and may not bill the recipient any
additional charge for the medically necessary private room.
A provider may bill a resident for the extra cost of a private
room if the private room is not medically necessary and is
requested by the resident. The provider must clearly inform the
resident that additional payment is strictly voluntary.
Medicaid will also pay for items under separate billable items. They are as follows: (a)
irrigation set for irrigation of ostomy;
ureterostomy supplies not otherwise listed;
disposable colostomy applicances and accessories;
implantable vascular access portal/catheter (venous arterial or peritoneal);
indwelling catheter, foley type, two-way, teflon;
indwelling catheter, foley type, two-way, latex;
indwelling catheter, foley type, two-way, latex with teflon coating;
indwelling catheter, foley type, two-way, all silicone;
indwelling catheter, foley type, two-way, silicone with elastomer coating;
indwelling catheter, foley type, three-way, latex or teflon for continuous
urinary collection and retention system, drainage bag with tube;
urinary collection and retention sytem, leg bag with tube;
catheter insertion tray, without tube and drainage bag;
(am) 3 - way irrigation set for catheter; (an)
oxygen contents, gaseous, per cubic feet;
oxygen contents, gaseous, per 100 cubic feet;
oxygen contents, liquid, per 100 pounds;
disposable humidifier(s) for respiratory therapies;
MADA plasatic nebulizer with mask and tube;
oxygen cart for protable tank (portable);
enteral feeding supply kit; syringe (monthly);
enteral feeding supply kit; pump fed (monthly);
enteral feeding supply kit; gravity fed (monthly);
nasal gastric tubing with thin wire or cotton (e.g., travasorb, entriflex, dobb huff,
enteral supply kit for prepackaged delviery system (monthly);
nasogastric tubing with or without stylet; (e.g., travasorb);
parenteral nutrition supply kit for one month - premix;
parenteral nutrition supply kit for one month - homemix;
parenteral nutrition administratio kit for one month;
enteral supplies not elsewhere classified;
parenteral supplies not elsewhere classified;
(cw) nutrient solutions for parenteral and enteral nutrition therapy when such
solutions are the only source of nutrition for residents who, because of
chronic illness or trauma, cannot be sustained through oral feeding.
Payment for these solutions will be allowed only where the department
determines they are medically necessary and appropriate, and authorizes
payment before the items are provided to the resident;
routine nursing supplies used in extraordinary amounts and prior
Carnation Instant Breakfast as a dietary supplement.
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