Louisiana Veterans Homes Application

APPLICANT INFORMATION

Please select appropriate choice below*

Veteran
Spouse of Veteran
Gold Star Parent

Preferred Facility*
Application Date*
MM slash DD slash YYYY

Full Name of Applicant*
Dates of Military Service (Upload Copy of DD-214)*
MM slash DD slash YYYY

Permanent Street Address*
Home Phone Number*
Mobile Phone Number*

City, State, Zip*
Branch of Service*
Social Sec. Number*

Parish Of Residence*
Service-Connected Disability Percentage*
VA Claim # (if Applicable)

Place Of Birth (City, State)*
Email Address (if Applicable)

Does The Applicant Require An Authorized Representative?*

Yes
No

Authorized Representative(s) or Emergency Contact Information

Please List Authorized Representative(s) First (if applicable)

Full Name
Relationship
Email Address

Street Address
City, State, Zip

Mobile Phone
Home Phone

Full Name
Relationship
Email Address

Street Address
City, State, Zip

Mobile Phone
Home Phone

Statement of History

Current Living Arrangement*

Home
Family
Hospital
Nursing Home
Other (Please explain in the next box)

If other, explain your current living arrangement.

Marital Status*

Married
Single
Divorced
Widow(er)

Religion (Optional)
Number of Children*

Highest Education Level*
Occupational History*

Insurance Information (Please check all that apply)*

Va Medical Benefits
Medicare Part A
Medicare Part B
Medicare Part D (pharmaceutical benefits)
HMO (humana, etc.)
Commercial Insurance (list information below)

Name*
Policy #*
Group #*

Address*
City, State, Zip*
Phone #*

Origin of Medication*

VA Clinic
VA Mail
Private Insurance
Other

Please attach a copy of all insurance cards for all policies (including medicare cards)*

Drop files here or

Max. file size: 40 MB.

Name of Hospital*
City, State*
Phone #*

Name of Physician*
City, State*
Phone #*

Funeral Home Preference*

Please attach a copy of any life insurance or burial policy information

Drop files here or

Max. file size: 40 MB.

Request for Medical Information

This part of the application must be completed by a doctor or nurse.

Upload a completed copy of the Medical Information sheet completed by your nurse or physician. You can download a printable copy of this form here. Click "Continue Later" at the bottom of this form if this document is not yet prepared for upload.

Upload completed medical information sheet here.*

Max. file size: 40 MB.

Veteran Benefits Documentation

The following documents (if applicable) are required for submission of claims for veterans benefits to the U.S. Department of Veterans Affairs:

Military Discharge (dd-214 or discharge papers)
Monthly Income
Marriage License
Divorce Decree
Birth Certificate (dependents age 0 - 17)
Post-High School Enrollment Verification (Dependents age 18 - 23)
Medical Insurance Verification (Copy of Insurance Cards)

Upload Veteran Benefit Documentation Files Here

Drop files here or

Max. file size: 40 MB.

IS THE VETERAN ENROLLED IN A VA HEALTH CARE PROGRAM AT ANY VA MEDICAL CENTER?*
- Yes
- No
Health Care Program Name*

LIST THE SOCIAL SECURITY NUMBERS FOR THE APPLICANT’S SPOUSE (IF APPLICABLE) AND ALL MINOR CHILDREN FOR WHOM THE APPLICANT IS FINANCIALLY RESPONSIBLE

Full Name of Spouse
Spouse Date of Birth
MM slash DD slash YYYY

Spouse Date of Death
MM slash DD slash YYYY
Spouse Social Security #

Veteran Child Info

Full Name of Dependent (Minor Child Only)	Date of Birth	Social Security #

Legal Procedure Disclosures

A copy of appropriate legal documentation to verify any ‘yes’ response must be attached to this application

HAS APPLICANT EVER BEEN INTERDICTED (DECLARED INCOMPTENT BY COURT OF LAW)?*

Yes
No

If yes, upload appropriate legal documentation to verify.*

Max. file size: 40 MB.

HAS APPLICANT AUTHORIZED ANYONE TO ACT AS HIS/HER AGENT OR ATTORNEY (POWER OF ATTORNEY)?*

Yes
No

If yes, upload appropriate legal documentation to verify.*

Max. file size: 40 MB.

DOES APPLICANT HAVE A DO NOT RESUSCITATE (DNR) REQUEST?*

Yes
No

If yes, upload appropriate legal documentation to verify.*

Max. file size: 40 MB.

DOES APPLICANT HAVE A LIVING WILL?*

Yes
No

If yes, upload appropriate legal documentation to verify.*

Max. file size: 40 MB.

DOES APPLICANT HAVE PENDING LEGAL CHARGES?*

Yes
No

If yes, please give a brief description.*

I ATTEST THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature of Applicant or Authorized Representative
Today's Date*
MM slash DD slash YYYY

Monthly Income Verification

VA SERVICE-CONNECTED COMPENSATION

VA SERVICE-CONNECTED COMPENSATION - Applicant*
Applicant ($) *
VA SERVICE-CONNECTED COMPENSATION - Spouse
Spouse ($)
VA SERVICE-CONNECTED COMPENSATION - Total*
Total ($) *

VA NON-SERVICE CONNECTED PENSION

VA NON-SERVICE CONNECTED PENSION - Applicant*
Applicant ($) *
VA NON-SERVICE CONNECTED PENSION - Spouse
Spouse ($)
VA NON-SERVICE CONNECTED PENSION - Total*
Total ($) *

SOCIAL SECURITY

SOCIAL SECURITY - Applicant*
Applicant ($) *
SOCIAL SECURITY - Spouse
Spouse ($)
SOCIAL SECURITY - Total*
Total ($) *

RETIREMENT

RETIREMENT - Applicant*
Applicant ($) *
RETIREMENT - Spouse
Spouse ($) *
RETIREMENT - Total*
Total ($) *

DIVIDENDS AND INTEREST

DIVIDENDS AND INTEREST - Applicant*
Applicant ($) *
DIVIDENDS AND INTEREST - Spouse
Spouse ($)
DIVIDENDS AND INTEREST - Total*
Total ($ *

REAL ESTATE

REAL ESTATE - Applicant*
Applicant ($) *
REAL ESTATE - Spouse
Spouse ($)
REAL ESTATE - Total*
Total ($) *

ALL OTHER ASSETS

ALL OTHER ASSETS - Applicant*
Applicant ($) *
ALL OTHER ASSETS - Spouse
Spouse ($)
ALL OTHER ASSETS - Total*
Total ($) *

PLEASE PROVIDE SUPPORTING DOCUMENTATION TO VERIFY THE INCOME NOTED ABOVE.*

Some examples are listed below:

Drop files here or

Max. file size: 40 MB.

VA Compensation	award letter, copy of most recent check VA Non-Service Connected Pension award letter, copy of most recent check
Social Security	copy of most recent check, last statement showing monthly income or bank statement records showing most recent deposit
Retirement	copy of most recent check, last statement showing monthly income or bank statement records showing most recent deposit
Dividends and Interest	copy of most recent check, last statement showing monthly income or bank statement records showing most recent deposit
Real Estate	copy of real estate agreement or copy of most recent canceled rent check
All Other Assets	copy of most recent statement of the income

EVERY RESIDENT OF THE FACILITY SHALL BE RESPONSIBLE FOR PAYMENT OF THE FULL RESIDENT CARE AND MAINTENANCE FEE. THE FACILITY’S ADMINISTRATOR MAY CONSIDER WAIVER OF PAYMENT OF CARE AND MAINTENANCE FEES ONLY FOR THE AMOUNT OF DIFFERENCE OF TOTAL INCOME OF THE VETERAN AND SPOUSE, WHEN APPLICABLE, AND THE TOTAL CHARGE FOR CARE AND MAINTENANCE.

THE CARE AND MAINTENANCE FEE FOR THE VETERAN IS CURRENTLY $1,794 PER MONTH. THE CARE AND MAINTENANCE FEE FOR THE SPOUSE OF A VETERAN OR A “GOLD STAR PARENT” IS $4,500 PER MONTH. PLEASE NOTE THAT THE CARE AND MAINTENANCE FEE RATE IS NOT GUARANTEED AND IT IS BASED ON QUALIFICATIONS. AT THE TIME OF ADMISSION, CARE AND MAINTENANCE FEES WILL BE ASSESSED ON ALL FAMILY INCOME SOURCES. FEES WILL BE ADJUSTED WHEN THERE IS A CHANGE IN FAMILY INCOME, RETROACTIVE TO THE CHANGE.

SIGNATURE OF APPLICANT/AUTHORIZED REPRESENTATIVE*
Date*
MM slash DD slash YYYY

SIGNATURE OF WITNESS*
Date*
MM slash DD slash YYYY

Authorization for Release of Protected Health Information (PHI)

Name of Applicant*
DOB*
MM slash DD slash YYYY

Address*
SSN*

City*
State*
Zip*

PROVIDER AUTHORIZED TO RELEASE THE PHI*

ENTITY RECEIVING THE PHI*

MAILING ADDRESS OF ENTITY*

ATTN:*

Purpose of this Disclosure:

Admission to Veterans Home

PHI AND DATES OF PHI AUTHORIZED FOR USE OR DISCLOSURE

Complete Health Record
- Complete Health Record
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

Progress Notes
- Progress Notes
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

Laboratory Tests
- Laboratory Tests
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

X-Ray Tests/Reports/Images
- X-Ray Tests / Reports/ Images
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

History and Physical Examination
- History and Physical Examination
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

Discharge Summary
- Discharge Summary
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

Consultation Reports
- Consultation Reports
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

Itemized Billing Statement
- Itemized Billing Statement
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

Diagnosis and Treatment Codes
- Diagnosis and Treatment Codes
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

Immunization Records
- Immunization Records
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

Other
- Other
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY

The following information will be released*

AIDS or HIV test results
Alcohol, drug or substance abuse treatment
Psychiatric or mental care / treatment
Other (specify)

I UNDERSTAND THAT:

1) I may refuse to sign this authorization, and it is strictly voluntary.
2) I may revoke the authorization at any time, in writing, to the provider authorized to release the protected health information, but, if I do, It will not have any affect on any actions taken prior to receiving the revocation.
3) I have the right of receive a copy of this form after I sign it.
4) A photocopy of this authorization will have the same effect as an original.
5) This authorization will automatically expire and be ineffective twelve months after date signed.

Signature of Patient
Date
MM slash DD slash YYYY

Signature of Representative (if necessary)
Personal Representative’s Relationship to Patient
Date
MM slash DD slash YYYY

Additional paperwork may be required.

An LDVA representative will be in touch if further paperwork is required to complete your application.

Louisiana Department of Veterans Affairs

Step 1 of 2

APPLICANT INFORMATION

Authorized Representative(s) or Emergency Contact Information

Statement of History

Request for Medical Information

Veteran Benefits Documentation

Legal Procedure Disclosures

Monthly Income Verification

Authorization for Release of Protected Health Information (PHI)

Purpose of this Disclosure:

PHI AND DATES OF PHI AUTHORIZED FOR USE OR DISCLOSURE

I UNDERSTAND THAT:

Additional paperwork may be required.

Please review your entry and submit the form.

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Louisiana Veterans Homes Application

Step 1 of 2

APPLICANT INFORMATION

Authorized Representative(s) or Emergency Contact Information

Statement of History

Request for Medical Information

Veteran Benefits Documentation

Legal Procedure Disclosures

Monthly Income Verification

Authorization for Release of Protected Health Information (PHI)

Purpose of this Disclosure:

PHI AND DATES OF PHI AUTHORIZED FOR USE OR DISCLOSURE

I UNDERSTAND THAT:

Additional paperwork may be required.

Please review your entry and submit the form.

Still have Questions?