401 bishop grady court application for bishop … you agree to execute all other documents necessary...

ServicesApplyingfor£ResidentialHabilitation£Respite£AdultDayTraining£SupportedEmploymentDateformcompleted______/______/__________Referredby__________________________________________ MM DDYYYY

PRIMARYINFORMATIONNameofApplicant__________________________________________________________________________________ LASTFIRSTMIDDLENAMEPreferstobeCalled________________________SSN#_________-_______-____________Sex£Male£Female XXXXXXXXXDateofBirth_____/______/__________PlaceofBirth__________________________________________________ MMDDYYYY CITY/TOWN STATE COUNTYPresentResidence__________________________________________________________________________________ STREET CITY STATE ZIPCODE COUNTRYResidency£FloridaResident£USCitizen£ResidentAlienLegalStatus£Competent£IncompetentReligion__________________________________£Baptized£Confirmed£ReceivedFirstCommunionFirstlanguage,ifotherthanEnglish______________PrimaryLanguageSpokenatHome________________________

FAMILYINFORMATIONParents’MaritalStatus£NeverMarried£Married£Widowed£Separated£Divorced_______________

DATE(MM/YYYY)

401BishopGradyCourtSt.Cloud,FL34769

Phone:407-892-6078Fax:407-892-3081

APPLICATIONFORBISHOPGRADYVILLAS

Parent/Guardian1£Mother£Father£Guardian

______________________________________________TITLE FIRST LAST SUFFIX

______________________________________________HOMEADDRESS

______________________________________________CITY STATE ZIPCODE

_____________________________________________HOMETELEPHONE CELLULARTELEPHONE

______________________________________________OCCUPATION/TITLE

______________________________________________BUSINESSNAME

______________________________________________BUSINESSADDRESS

_____________________________________________BUSINESSTELEPHONE BUSINESSFAX

______________________________________________PREFEREDEMAIL

_______________________DATEOFBIRTH(MM/DD/YYYY)

Parent/Guardian2£Mother£Father£Guardian

______________________________________________TITLE FIRST LAST SUFFIX

______________________________________________HOMEADDRESS

______________________________________________CITY STATE ZIPCODE

_____________________________________________HOMETELEPHONE CELLULARTELEPHONE

______________________________________________OCCUPATION/TITLE

______________________________________________BUSINESSNAME

______________________________________________BUSINESSADDRESS

_____________________________________________BUSINESSTELEPHONE BUSINESSFAX

______________________________________________PREFEREDEMAIL

_______________________DATEOFBIRTH(MM/DD/YYYY)

GENERALAPPLICANTINFORMATIONCommunicationModality£Verbal£PartiallyVerbal£Non-Verbal£Sign£CommunicationDevice

£Other,pleasespecify__________________________________________________MealtimeStatus£EatsIndependently(withorwithoutadaptiveequipment)£RequiresSupporttoEat

£RequiresPhysicalAssistance/Equipment£RequiresPositioningEquipmentDietaryGuidelines__________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________FoodTexture£Foodeatenatnormalconsistency

£Foodconsistencyaltered(pleasespecify):£chopped£ground£puree£usesthickerFeedingGuidelines__________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________Mobility£Walksonown£WalkswithAssistance£UsesWalker£Usesacane£Wheelchair£Other

Mobility/AdaptiveEquipmentComments_____________________________________________________________

__________________________________________________________________________________________________Supervision£NoSupervision£Supervisionforpersonalcare£Assistanceforpersonalcare

£Assistanceforeverything£Neverunattended£Lineofsight£Arm’slength£OtherSupervisionComments______________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________ToiletingStatus£ToiletsIndependently£RequiresPhysicalAssistance/Equipment£ScheduledBowelProgram

£ScheduledBladderProgram£RequiresPrompt/Monitoring£RequiresDisposableBriefsToiletingStatusComments___________________________________________________________________________

__________________________________________________________________________________________________BathingStatus£Independent£RequiresSupporttoBath/Shower£IndependentwithDevicesBathingStatusComments____________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

MEDICALDIAGNOSIS&INFORMATIONDevelopmentalDisability£CerebralPalsy£SpinaBifida£Autism£Prader-WilliSyndromeCHECKALLTHATAPPLY£IntellectualDisabilityIntellectualDisability£Mild£Moderate£Severe£Profound£Unspecified£N/APLEASECHECKONEPleaselistALLadditionalMedicalDiagnoses(i.e.ADHD,Bipolar,HighBloodPressure,NeurologicalImpairment)______

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________FoodAllergies£No£Yes,pleasespecify______________________________________________________________MedicationAllergies£No£Yes,pleasespecify________________________________________________________BloodType£A+£A-£B+£B-£AB+£AB-£O+£O-£UnknownSeizureActivity£No£Yes,pleasespecifytypeandfrequency_____________________________________________Hasthereeverbeentreatmentforemotional/behavioralproblemsorapsychiatriccondition?£Yes£NoPLEASEDESCRIBEBREIFLYBELOWANDATTACHANADDITIONALSHEETOFEXPLANATION.

____________________________________________________________________________________________________________________________________________________________________________________________________Hastheapplicanteverengagedinviolentactivityorbeendiagnosedwithhavingviolenttendencies?£Yes£No

IfYes,pleaseexplainindetail_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hastheapplicantevenbeendeniedadmissiontoordischargedfromanyschool,residentialfacility,orothercaregivingentity?£Yes£No

IfYes,pleaseexplainindetail_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hastheapplicanteverbeenaccusedorconvictedofacrime?£Yes£NoIFYES,PLEASEATTACHUSEANADDITIONALSHEETANDEXPLAINTHECIRCUMSTANCES.

MedicalDiagnosis&InformationContinuedonNextPage

MEDICALDIAGNOSIS&INFORMATION(continued)Pleaselistanysharedmedical/dentalcontacts(i.e.physicians)thatyougivepermissionforustocommunicatewith.

__________________________________________________________________________________________________FIRSTNAME LASTNAME SPECIALITY CONTACT



__________________________________________________________________________________________________FIRSTNAME LASTNAME SPECIALITY CONTACTPleaselistallmedicationtheapplicanthastakenorbeenprescribedinthepastfiveyears:

______________________________________________________________________________________________MEDICATION PRESCRIBEDFORMEDICATION PRESCRIBEDFOR




Pleasedocumenthospitalizationsandmajorsurgeriesbelow:PLEASEATTACHANADDITIONALSHEETIFNECESSARY

____________________________________________________________________________________________DATE(MM/YY) HOSPITAL REASONFORHOSPITALIZATIONORSURGERYPERFORMED



EDUCATIONDidyougraduatehighschool?£Yes£NoIfYes,didyoureceive(CHECKONE)£RegularDiploma£SpecialDiplomaPleaselistallsecondary(high)schoolsyouhaveattended.Pleasestartwithmostcurrent.

________________________________________________________________________________________________NAMEOFSCHOOL LOCATION(CITY,STATE,ZIPCODE) DATESATTENDED(MM/YYYY)

________________________________________________________________________________________________NAMEOFSCHOOL LOCATION(CITY,STATE,ZIPCODE) DATESATTENDED(MM/YYYY)

________________________________________________________________________________________________NAMEOFSCHOOL LOCATION(CITY,STATE,ZIPCODE) DATESATTENDED(MM/YYYY)Ifanyofthefollowingapplytoyoursecondaryschooleducation,pleasechecktheappropriatebox.

£Graduatedearly£Graduatedlate£Willnotgraduate,willreceiveGED£Willnotgraduate,willnotreceiveGED

WORKEXPERIENCE/HISTORYPleaselistallworkexperienceandhistorybelowbeginningwithmostcurrentorpresentemployer.CURRENTORMOSTPREVIOUSEMPLOYERNAMEOFEMPLOYERADDRESSCITY,STATE,ZIPCODEPHONENUMBER

NAMEOFLASTSUPERVISOR EMPLOYMENTDATES PAYORSALARY

FROMTO

STARTEND

JOBTITLE

BRIEFJOBDESCRIPTION

PREVIOUSEMPLOYERNAMEOFEMPLOYERADDRESSCITY,STATE,ZIPCODEPHONENUMBER


FROMTO

STARTEND

JOBTITLE

BRIEFJOBDESCRIPTION



FROMTO

STARTEND

JOBTITLE

BRIEFJOBDESCRIPTION



FROMTO

STARTEND

JOBTITLE

BRIEFJOBDESCRIPTION

VOLUNTEERHISTORYPleaseattachanadditionalsheetindicatinganyvolunteerhistory,ifapplicable.

BENEFITSMEDICAREMEDICAIDMEDICAIDWAIVER

BenefitsContinuedonNextPage

WaiverRecipient?£Yes£NoIFNO Istheapplicantonthewaitlist?£No£Yes(IfYes,seebelow) Whatistheeffectivedateonthewaitlist?_____/______/______IFYES _________________________________________________________________________________ SUPPORTCOORDINATORNAME

_________________________________________________________________________________ADDRESS________________________________________________________________________________

PRIMARYPHONE SECONDARYPHONE Whatservicesareyoucurrentlyreceivingthroughthewaiver?______________________________

_________________________________________________________________________________

IfyoureceiveResidentialHabilitation,whatisyourcurrentlevel?____________________________AreyouparticipatingintheConsumerDirectedCarePlus(CDC+)program?£Yes£No

MedicareRecipient?£Yes£NoIFYES MedicareNumber_____________________MedicareEffectiveDate________________________

MedicareSection(CHECKALLTHATAPPLY)£A£B£D

AreyouparticipatinginaMedicareAdvantagePlan(PartC)?£Yes£No COMPLETEBELOWIFPARTOFMEDICARESECTION“D”

_______________________________________________________________________________________MEDICAREPLANDID MEDICAREPLANDPLAN MEDICAREPLANDISSUER

_______________________________________________________________________________________MEDICAREPLANDRxBIN MEDICAREPLANDRxPCN MEDICAREPLANDRxGRP

MedicaidRecipient?£Yes£NoIFYES MedicaidNumber_____________________

BENEFITS(continued)PRIVATEINSURANCESOCIALSECURITYBENEFITS

VOCATIONALREHABILITATIONFOODSTAMPSADDITIONALINFORMATIONAretherecontributingfactorsintheapplicant’slifethatwouldcharacterizehisorherplacementneedsasurgent(i.e.death/illnessofparentorsignificantcaregiver)?£Yes£NoWillyouagreetoexecuteappropriatelegalpapersallowingBishopGradyVillasstafftoadministermedicalassistanceortoarrangeformedicaltreatmentwhennecessary?£Yes£NoWillyouagreetoexecuteallotherdocumentsnecessaryforthecare,transportationandhousingoftheapplicant?£Yes£NoPleasesee“SupplementalForms&Photocopies”Sheetforadditionalinformationtocompletetheapplicationprocess.

InsuranceCompany________________________________PolicyNo_______________________________Pleasecompletethefollowinginformationinregardstothepolicyholder

______________________________________________________________________________________NAME DATEOFBIRTH(MM/DD/YYYY) SSN(XXX-XX-XXXX)RelationshiptoPolicyHolder£Self£Spouse£Child£Other

IncomeBenefits$______________$______________$______________$______________ SSI SSDI PENSION OTHER:__________AreyouparticipatinginaPASSplan?£Yes£NoAreyouaTickettoWorkrecipient?£Yes£No

AreyouaclientofDepartmentofVocationalRehabilitation?£Yes£NoIFYES CounselorName____________________________________________________________________

HaveyoureceivedFoodStampsinthepast12months?£Yes£No36months?£Yes£No

CERTIFICATIONANDRELEASETheundersignedherebycertifythattheforegoinginformationistrueandcorrect,andtherearenoomissionsinthisapplication.Theundersignedhaslegalauthoritytorepresentandbindtheapplicant.We/IauthorizeBishopGradyVillastocontactallmedicalproviders,schools,employers,andcare-giversidentifiedinthisapplication,andexpresslyauthorizethoseidentifiedtoreleaseanyandallinformationconcerningtheapplicantandabsolvethemfromanyandallpossibleliabilityarisingoutofsuchreleaseordisclosure.Anyandallreferenceorbackgroundchecksareexpresslyauthorized.Finally,theundersignedrecognizeandacknowledgethatanyinaccuraciesoromissionsinthisapplicationwillresultinthedenialoftheapplication,or,ifdiscoveredaftertheapplicanthasbecomearesident,immediatedischarge. MEDIA&PUBLICITYRELEASEIauthorizeBishopGradyVillastousephotographs,slides,orvideosoftheapplicanttopromoteBishopGradyVillas,toassistinfundraising,andforallotherpurposesdeemedappropriatebyBishopGradyVillas'stafforitsBoardofDirectors.IalsoreleaseBishopGradyVillas,itsofficers,directors,shareholders,volunteers,employeesandagentsfromanyandallliabilityarisingoutoftheuseoftheapplicant'sphotographs,slidesorvideos.WITNESSESWitnessesarerequiredonlyifthisapplicationhasbeensignedbymark(X)above.Ifsignedbymark(X),twowitnessestothesigningwhoknowtheapplicantmustsignbelow,givingtheirfulladdress.BishopGradyVillasisalicensedALFfacilitythroughtheStateofFlorida,license#AL10398,Certificate#40733,effective12/26/2013

______________________________________________APPLICANT’SSIGNATURE/MARK_____/______/__________MMDDYYYY __________-_______-_____________XXXXXXXXX

______________________________________________PARENT/GUARDIAN’SSIGNATURE_____/______/__________MMDDYYYY __________-_______-_____________XXXXXXXXX______________________________________________RELATIONTOAPPLICANT

______________________________________________APPLICANT’SSIGNATURE/MARK_____/______/__________MMDDYYYY

______________________________________________PARENT/GUARIDAN’SSIGNATURE_____/______/__________MMDDYYYY ______________________________________________RELATIONTOAPPLICANT

______________________________________________SIGNATUREOFWITNESS______________________________________________ADDRESSOFWITNESS______________________________________________CITY STATE ZIPCODE

______________________________________________SIGNATUREOFWITNESS______________________________________________ADDRESSOFWITNESS______________________________________________CITY STATE ZIPCODE

1.RegardingIndividualName–First,Last,MIAddress

Telephone#

City State

ZIPCode

SocialSecurity# BirthDate

2.RecordsReleasedFrom 3.RecordsReleasedToName-(i.e.HealthFacility,Physician) Name

BISHOP GRADY VILLASAddress Address

401 BISHOP GRADY COURTCity State ZIP City

ST.CLOUDStateFL

ZIP34770

Telephone# Fax# Telephone#(407) 892-6078

Fax#(407) 892-3081

4.InformationtobeReleased(Checkallapplicable)£Completecopyofallrecords £Itemization/coding £SocialServiceReports£Telephone/VerbalCommunication £ImmunizationRecord £SpeechandHearingReports£Counseling&ConsultationVisits £AllergyRecords £PhysicalTherapyReports£LabReports £X-rayReports/Films £AcademicRecords£HabilitationPlans/SupportPlans £OccupationalTherapyReports £PsychologicalReports£Clinicrecordspertainingtooutpatienttreatmentof(specifyapproximatedate(s)orcondition)____________________________£Other__________________________________________________________________________________________5.Informationrequestedabovewillbeused/disclosedforthefollowingpurposes£FurtherMedicalCare£Personal£RecordsofResidentialFacility£Other______________________________6.Thisauthorizationwillremainineffectfornolongerthan90calendardaysunlessyouspecifythisauthorizationwillbeeffectiveforanadditiontimeperiod.£None£Additionaltimeperiod.Specify____________________________________________________7.Iunderstandthatinformationmayonlybere-releasedwithmyapprovalexceptasrequiredbylaw.However,Iunderstandthatifthereceiveroftheinformationisnotahealthcareproviderorhealthplancoveredbyfederalprivacyregulations,theinformationdescribedabovemaybere-disclosedandnolongerprotectedbytheseregulations.8.IunderstandthatImayrefusetosignthisauthorizationandthatmyrefusaltosignwillnotaffectmyabilitytoobtainservicesormyeligibilityforbenefits.Imayinspectorcopyanyinformationused/disclosedunderthisauthorization.IunderstandthatImayrevokethisauthorizationinwritingatanytimebycontactingBishopGradyVillas,exceptwhentherequestedinformationhasalreadybeensent,basedonthisauthorization.9.IcertifythatIunderstandtheabovestatementseitherpersonallyorthroughmylegalrepresentative._______________________________________________________________________________________________SignatureofIndividualorLegalRepresentative PrintedName Date

Ifthisauthorizationhasbeensignedbyapersonalrepresentative(above)onbehalfofanindividual,his/herauthoritytoactonbehalfoftheindividualmustbesetforthhere:________________________________________________________________

BISHOPGRADYVILLAS401BishopGradyCourtSt.Cloud,FL34770Phone:(407)892-6078|Fax:(407)892-3081

CONSENTTOOBTAINORRELEASECONFIDENTIALINFORMATION

SupplementalForms&PhotcopiesRequiredForthoseapplyingtoBishopGradyVillas

SUPPLEMENTALFORMSConsenttoObtainorReleaseConfidentialInformationThisformistobeusedeachtimethatconfidentialinformationisneededfromanoutsideparty/provider.Multiplesheetsmaybeneeded.PHOTOCOPIESREQUIREDPleaseprovidephotocopiesofBOTHfrontandbackofthefollowingdocumentsfortheapplicant.Achecklistofthedocumentshasbeenprovidedforyourconveniencebelow:DocumentsREQUIRED:☐StateID/DriversLicense ☐Psychevaluationwithadaptivetesting*

☐BirthCertificate

DocumentsREQUIRED,ifapplicable:☐MedicareCard ☐MedicarePartD(DrugPlan)

☐MedicaidGoldCard ☐PrivateInsuranceCard

☐CourtOrderofLegalGuardianship/PowerofAttorney ☐WaiverorStateSupportPlan?

Ifapplicable,pleaseprovide:☐MedicaidWaiverWaitListEnrollmentLetter(forthosenotcurrentlyreceivingwaiverservices)

☐BaptismCertificate

☐ConfirmationCertificate

*Ifapsychologicalevaluationisnotavailable,theWaiverorStateSupportplanmaybesubmittedtodetermineeligibility.