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Financial Checklist Prior to Admission (Form 1b)

  1. sign
  2. Financial Checklist Prior to Admission (Form 1b)
  3. This financial check list must be completed by responsible party and turned into the Administrative Assistant before admission.
  4. Check the Yes or No to the following questions
  5. 1. Social Security award letter (formerly TPQY), VA verification, RR verification, or ANY
  6. 2. Income verification
  7. 3. Medicare, Medicaid cards, verification what type of Medicaid, ie: spend down
  8. 4. Current bank statement for checking and savings
  9. 5. Copy of life insurance – verification of cash value
  10. 6. Copy of irrevocable funeral trust
  11. 7. Proof of assets, car, house, land cd’s alimony, child support, or stocks & bonds and cash value
  12. 8. Copy of birth certificate
  13. 9. Copy of marriage certificate or divorce decree
  14. 10. Copy of guardianship papers
  15. 11. Copy of Power of Attorney papers
  16. The admission team will review the above information and will contact the applicant in a timely manner.
  17. Leave This Blank:

  18. This field is not part of the form submission.