Applicant Information
Full Name: Phone Number:
Date of Birth: Social Security # :
Insurance Information
Medicare #: (If applicable) Medicaid #:
Other Coverage :
Responsible Party Information (Who is handling financial matters)
Full Name: Relationship:
Address: City: State: Zip:
Phone Number: Work Number:
Income
Social Security $: per month
Pension $: per month
S.S.I $: per month
Other $: per month
Payment Sources

We do accept Medicaid, however there are a limited number of apartments designated to this payment source. Currently there is a Medicaid waiting list for Christian Care members as well as people inquiring from the community. If a medical apartment is not available at the time you/your loved one is in need, the family may choose to pay the difference between the private rate and the Medicaid rate until an appropriate apartment becomes available.

Christian Care members have precedence over people coming from the community. Therefore, if you are admitted into a private room it is important for us to establish the length of time prior to changing payment sources.

Based on your current level of care costs (Level 1, 2 or 3), Please estimate the length of time before you would need to change payment sources: month/years
Entry Fee

$1200 for new members. This is paid $50.00 per month for 24 months, in addition to your regular level of care costs. Members may pay it in full or in advance, however, it is deemed necessary to process my application.

I authorize CHRISTIAN CARE Senior Care Community to make such investigations as deemed necessary to process my application.

Signature: ___________________________________

Date: _________________