Apply for Admission to Lutheran Sunset Home

You or your loved one deserves to live in a place that feels like home. Complete and submit this online form to start the process.

Step 1 of 6

Identification
Name(Required)
First Middle Last
Email(Required)

Phone(Required)
Applying for Admission to:

Nursing Home

Assisted Living
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Information
Birth Date(Required)
MM slash DD slash YYYY

Sex
Race
Marital Status
Spouse Name
Previous Occupation
Education
Religion
Church:
(Name, Address, City, Phone)
Birthplace
Military Veteran Status:
Resident

Yes

No
Branch
Spouse (Name)
Spouse

Yes

No
Branch
Have you ever been convicted of or pled guilty to a sexual offense in a court of law?

Yes

No

Medical Designations
Local Physician(Required)
Phone No
Local Optometrist/Ophthalmologist(Required)
Phone No
Local Dentist(Required)
Phone No
Local Pharmacy(Required)
Phone No
If outside of Grafton, Primary MD
Phone No
Notify In Emergency
1) Name(Required)
Relationship(Required)
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone No (H)(Required)
Phone No (W)
Phone No (C)
Email(Required)

2) Name
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone No (H)
Phone No (W)
Phone No (C)
Email

3) Name
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone No (H)
Phone No (W)
Phone No (C)
Email

Billing Party
(who we send the billing statement to)
Name(Required)
Relationship(Required)
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone No (H)(Required)
Phone No (W)
Phone No (C)
Advanced Directives
Please list Power of Attorney (POA) as described in legal document*
POA for Financial
POA for Healthcare
OR POA FOR BOTH
If no legally designated Power of Attorney, please list appointed decision makers:
Medical Decision Maker
Financial Decision Maker
*Please provide Lutheran Sunset Home with a copy of these documents*
Funeral Home Preference
Name(Required)
Address
Phone No
Is the burial prepaid?

Yes

No
Amount ($)

Insurance Information
Medicare Number(Required)
Part A

Yes

No
Effective Date
MM slash DD slash YYYY

Part B

Yes

No
Effective Date
MM slash DD slash YYYY

Medicare Supplement Ins
Policy No.
Address
Phone No
Do you have a Medicare Replacement policy

Yes

No
If yes, Name
Address
Phone No
Is Applicant currently receiving Medicaid?

Yes

No
Medicaid ID No. (If Applicable)(Required)
County
Pending
Approved
Approved Date
If no, will financial assistance be needed?

Yes

No
Has an application been submitted for Medical Assistance?

Yes

No
If yes, what county?
Long Term Care Ins:
Policy No
Address
Phone No
Long Term Care Ins:
Policy No
Address
Phone No
Do you have a Medicare D (prescription drug) Plan?

Yes

No
Effective Date
MM slash DD slash YYYY

Plan Name
Policy No
Other Insurance

Except for personal affects, list all assets owned by you and your spouse, with the value as of the date of application.
Include checking, saving-passbook, certificate(s) of deposit, stocks, bonds (etc.), life insurance, cash surrender value, home(s), land, vehicles, life estates and trusts, annuities & retirement funds (401(k), IRA, Roth), prepaid burial, other (describe)(Required)
Owner(s) of Asset
Description of Asset
Approximate Value

Include checking, saving-passbook, certificate(s) of deposit, stocks, bonds (etc.), life insurance, cash surrender value, home(s), land, vehicles, life estates and trusts, annuities & retirement funds (401(k), IRA, Roth), prepaid burial, other (describe)
List all debts owed by you and your spouse, with outstanding balance as of the date of application.
(Required)
Debtor
Description of Debt
Amount of Debt

List all transfers of cash and/or gifts of assets within the past five years, by you and your spouse, including transfers of a remainder interest in real property.
(Required)
Date of Transfer
Description of Asset
Recipient/Relationship
Value of Asset

Did the agent or attorney-in-fact under your financial power of attorney assist you with making any of the transfers or gifts referenced above, or benefit or receive any of the assets transferred or gifted? If yes, please explain.
Were any of the assets described transferred to or from a trust? If yes, explain the nature of the transaction and identify the trust involved.
List all sources of income for you and your spouse, including but not limited to rental payments, CRP income, long term care insurance benefits, Social Security benefits, Veteran benefits, and employment income.
(Required)
Description of Income
Date of Frequency of Payment (i.e. Monthly, annually, etc.)
Amount of Payment

Do you or your spouse reside on a farm?

Yes

No
Are you actively engaged in farming or any other trade or business? If yes, describe the nature of the business.
Are you or your spouse employed by another or self-employed? If yes, provide the name of the employer or the nature of self-employment, the hours worked and the wage or salary earned.
Are you or your spouse the beneficiary of any trust?

Yes

No
Do you have any pending legal action from which you may receive money or medical benefits, including inheritance?

Yes

No
If yes, describe.
Signature(Required)
(Resident/Legal Agent/Responsible Party)
First Last
Date(Required)
MM slash DD slash YYYY

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