Arizona State Veteran HomeApplication PacketArizona State Veteran Home - Tucson555 East Ajo Way, Tucson, AZ 85713Arizona State Veteran Home - Phoenix4141 North Silvestre Herrera Way, Phoenix, AZ 85012Arizona State Veteran Home - Yuma6051 East 34th Street, Yuma, AZ 85365Admissions Hotline: 602-234-56781 Arizona Department of Veterans’ Services. All rights reserved. (rev.2021-12-27.pia)

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONFrequently Asked QuestionsQ: What are the eligibility requirements for admission?A: Any Veteran (with the exception of those dishonorably discharged); Spouse of a Veteran; orGold Star Family MembersQuestion: What is the daily rate for private pay?Answer (Phoenix): 165 per day / 4,950 per monthAnswer (Tucson): 227 per day / 6,831 per monthAnswer (Yuma): 280 per day / 8426 per monthQuestion: What insurance is taken?Answer (Phoenix): All providers under Medicaid; additionally, some Medicare supplements are taken(please contact in admissions specialist at (602-248-1594 to verify your eligibility).Answer (Tucson): Medicare A and Mercy Care Advantage Plan are the only Medicare advantage planstaken (please contact in admissions specialist at (520-638-2150 to verify your eligibility).Answer (Yuma): TBDQuestion: Are there any programs to assist with costs?Answer: Medicaid, Arizona Long Term Care (ALTCS), non-service connected pension, and aid andattendance, if eligible.Question: Are there any cost breaks for service-connected disabled veterans?Answer: Yes, the VA will pay for the Veteran if they have a 70% service-connected disability rating orhigher.***An ADVS Veteran Benefits Counselor (VBC) can assist with filing a VA Disability/compensation claim, please call (602)535-1215 to speak with a VBC***Question: What is the capacity of the homes and what is the occupancy breakdown of therooms?Answer (Phoenix): The max occupancy is 200 beds and there are 8 single rooms and 192 semi privatedouble occupancy rooms.Answer (Tucson): The max occupancy is 120 beds, all of which are private rooms.Answer (Yuma): The max occupancy is 80 beds, all of which are private rooms.RecreationQuestion: Are there recreation activities available?Answer: Yes, our Recreation Department plays a vital role in the Veteran’s care. Services from thisdepartment make available a therapeutic approach focusing on mind, body, and spirit, bringing balanceto one’s life. These services are incorporated in the plan of care.Care Plans and SafetyQuestion: What is the visitation policy at the homes?Answer: There are no defined visiting hours, however, we ask you to consider other residents who maybe sleeping if visiting during unusual times.2

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONQuestion: What care options are available?Answer: Arizona State Veteran Homes are long-term skilled nursing facilities that provide 24-hourcare for our residents. Additionally, every home has a professional staff that consists of CNA,LPN,Nursing, Resident Physician, Physical Therapy and Dietary. Also, each home is equipped with aMemory Care Unit, which is available to cognitive impaired Veterans at high risk of elopement.Question: How is my level of care determined?Answer: Upon move-in, our nurses and care team will assess your current health and review yourmedical history to see how we can best meet your needs. They will also discuss your preferences aswell as your normal routines to develop a care plan that’s tailor made for you. This Individualized ServicePlan (ISP) details your care plan and is regularly updated to meet your evolving needs.Question: Is Short-Term rehabilitation available?Answer: Yes, If the applicant needs short-term rehabilitation, they must have traditional Medicare or aservice-connected disability of 70% or higher.Question: Do residents still have access to medical care outside of the facility?Answer: Yes.Question: Is transportation provided for medical appointments?Answer: Yes.Question: Is Therapy offered?Answer: Yes, offers skilled therapy and therapy to our long-term care veterans. These services includePhysical Therapy, Occupational Therapy and Speech Therapy. Therapy services are provided bytherapists and assistants in a fun, fast paced gym, located in our facility. Our Veterans receive therapythat is patient focused in a family-oriented environment. Our size allows us the opportunity to beresponsive and innovative and to provide very personalized care, utilizing a team approach. Thededication and experience of our staff are key to our success.Question: Is assistance offered to residents that have experienced falls in the past?Answer: Yes, we develop an Individualized Care Plan (ISP) for each resident that details care needsand preferences and addresses safety concerns. If falling is a concern, the ISP may includeinterventions and special precautions to help address this issue that will be followed by our DesignatedCare Managers.Question: Do you have a medication management program?Answer: Yes, our homes have a medication management program, which may be added to anIndividualized Service Plan (ISP) and varies based on regulation. Residents participating in themedication program may choose their own pharmacy or use the home’s preferred pharmacy provider inthat region. If a resident prefers to use an alternate pharmacy, the resident and pharmacy must complywith certain requirements. Additionally, residents may be assessed to self-administer medications.Question: Is social services available at the homes?Answer: Yes3

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONMission Statement: The mission of the Arizona State Veteran Homes is to provide professionalskilled nursing and rehabilitative care for the geriatric and chronically ill Veteran anddependent/surviving spouses throughout the State of Arizona. Our goal is for each veteran to attain ormaintain his or her highest practicable physical, mental and psychosocial well-being.Thank you for your interest in applying for residency to one of our Arizona State Veteran Homes.This application packet includes the complete package that is required to be completed foradmission to one of the Arizona State Veteran Homes.TABLE OF CONTENTSDescriptionFAQsApplication InstructionsAdmission QualificationDocument ChecklistSection A – General InformationSection B – Resident/Patient Health InformationSection C – Physician’s Medical Certificate (Completed by Physician)Section D – Functional Assessment (Completed by Applicant or Representative)Page24556111316APPLICATION INSTRUCTIONSIf you need assistance in completing the application or if you have any questions, see page 10 inSection A of this application.Follow the instructions below to begin the application process. If a spouse or domestic partner isalso applying, please submit a separate application. In order to expedite the admissions processplease take the following steps:1. Complete Section A and Section B of this application.2. Provide Section C to your primary care physician for completion. Contact yourphysician as soon as possible for an exam to complete the section in its entirety.Section C is only valid for 6 months and depending on your admission date it maybe necessary to complete Section C again to ensure it is valid.3. To ensure care needs are able to be met for all admissions to the home, currentmedical records must be reviewed.4. Include copies of current Advanced Directives, Power of Attorney, Court appointedConservatorship or Guardianship, and Living Will.5. Completed application packages must include all required documents that areincluded on the “Document Checklist” found on page 6.6. Submit completed applications via fax, email or mail to the Arizona State VeteranHome of your choice. Contact information is on page 10.We look forward to working with you and ask that you please call the admissions team at theArizona State Veteran Home if you should have questions while completing this application.4

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONAdmission QualificationsTo be admitted to an Arizona State Veteran Home the applicant must be a Veteran, a VeteranSpouse, a surviving spouse, or an immediate Gold Star family member and the followingrequirements must be met:ApplicationA. An applicant or legal representative shall apply for admission to an ASVH by submitting acompleted ASVH application to the admissions coordinator. If both a Veteran and theVeteran’s spouse are applying for admission, both shall file separate applications. Anapplication may be obtained from an ASVH or from the agency website at www.azdvs.govB. In addition to the ASVH application required under subsection (A), an applicant or legalrepresentative shall submit the following:1. Information regarding the applicant's ability to participate in daily living activities and theapplicant's psychosocial behavior. The information may be provided through either of thefollowing:a. A functional questionnaire form provided by ASVH that is completed by the applicant orfamily member, orb. The equivalent medical information provided by a health care provider;2. A completed applicant's financial information statement on a form provided by ASVH;3. A completed physician's statement by the applicant's physician on a form provided byASVH or equivalent medical information;4. A copy of the veteran's discharge document from the United States military, a certifiedcopy of the separation or discharge document issued by the National PersonnelRecords Center, or a Statement of Service issued by the VA Regional Office;5. If requested by the director of nursing, a copy of medical records that assist in determiningthe level of care required by the applicant. Medical records may include physician'srecords, nurses' notes, test results, and medication records; and6. Evidence of freedom from infectious pulmonary tuberculosis.C. Evidence of treatment at a VA Medical Center will satisfy the requirement in (8) (4) ofthis section.5

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONDOCUMENT CHECKLISTIn order to assist our applicants, we have provided the following document checklist. Pleaseensure all required documents are available or admission could potentially be delayed. IDENTIFICATIONo DD Form 214: Certificate of Dischargeo Birth Certificateo Driver’s License/Identification Card (State Issued)o Social Security Card MEDICAL INSURANCEo Arizona Health Care Cost Containment System (AHCCCS) Cardo Medicare Cardo VA Medical Cardo Dental or Other Insurance Card LEGAL/OFFICIAL PAPERSo Advanced Directiveso Power of Attorney and/or Durable Power of Attorneyo Marriage Certificate (if currently married)o Final Divorce Decree (if applicable)o Pre-Arranged Burial Plano Will or Trust6

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONSECTION AGENERAL INFORMATIONPlease let us know how you heard about us:PERSONAL INFORMATION1. Applicant Name:2. Current Residence:LastFirstMiddleAddress3. Mailing Address (if different):CityAddressStateCity(County)6. /Pacific IslanderCityBlackZipZipTelephone4. Social Security Number:5. Date of Birth:MaidenMaleFemaleStateCountyAmerican Indian/Alaska NativeOther (specify):7. Religious Preference:8. Marital Status:MarriedWidowedDivorced7SeparatedNever Married

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION9. Spouse’s Name:LastFirstMiddle10. Work History:Previous occupationKind of business11. Responsible Party:Full Name()Phone NumberRelationshipAddress12. Emergency Contact 1:ZipRelationshipCityEmergency Contact 2:StateWork phone numberFull nameAddressPhone numberStateZipFull NameAddressRelationshipCity13. Date of: / /Enlistment14. Branch:CityEmail addressMaidenArmyPhone numberState/ /NavyDischargeMarinesZipEraU.S. Coast GuardAir ForceMerchant Marine15. Check all that apply:WACSWAAFWMCSPARSNurse Corps16. Does applicant have a service-related disability?Yes17. If yes, what is the percentage?18. Applicant’s Armed Services Serial Number19. Applicant’s Dept. of Veterans Affairs Claim or File Number8NoPOW

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION20. Applicant represented by a Veteran Service Organization?YesNoPOA?21. Insurance:22. Has applicant signed up for Medicare?23. If yes:Part APart BNoYesQMBSLMBMedicare Number24. Is applicant currently on AHCCCS?If yes, plan and number:Yes25. Is applicant currently on ALTCS?NoYesNoPID numberName of ALTCS Case Manager:26. Does applicant have other insurance?YesNoIf yes, please provide the following: Name of insurance:Policy number:Address of company:Phone number of company: ()27. Does applicant have nursing home insurance?NoIf yes, attach a copy of the policy28. Service organization membership (VFW, Elks, etc.):29. Advance Directives:30. Does applicant have a: (Check if yes, attach a copy of the documentation)Power of attorneyCourt appointed guardianship or conservatorshipLiving willHealth care power of attorney31. Name of agent:Address(Relationship:CityState)Telephone number9Zip

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION32. Provide name, address and telephone number of preferred Funeral Director:Name:Phone number: (Address)CityStateZip33. Provide name, address and telephone number of preferred cemetery:Name:Phone number: (AddressCity)StateZipArizona State Veteran Home PreferenceThe Arizona Department of Veterans’ Services operates 2 State Veteran Home. Select yourpreference for the Home(s) you are applying to. Mark “1” for your first choice, “2” for yoursecond choice, and so on. If you are not interested in a specific Home, mark an “X” next to “Ido not wish to apply for this location.” In the event the location you have selected has noavailability you will be informed and given the option to automatically be considered for yoursubsequent preferences or you may elect to wait for your desired location to have availability.Your completed application and required records should be submitted only to your first choice.If you decide to revise your order of priority simply contact the Home and request they forwardyour application and required information to your new preferred Home.LocationASVH-PhoenixASVH-TucsonASVH-YumaOrder ofPreference###Check if Not Interested Not Interested in this locationNot Interested in this locationNot Interested in this locationApplication Assistance and SubmissionIf you need assistance filling out the application or have any questions, contact any of the locationsbelow. Please submit your completed application via fax, email or mail to your Home of ephone602-234-5678602-234-5678602-234-5678Fax Number602-263-1826602-773-0935928-569-571210Email [email protected]

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONApplicant/Legal Representative: Read the following and Sign:I further declare that I am a legal resident of the State of Arizona. I will submit a copy ofHonorable or General discharge documentation from the military service of the UnitedStates. I will inform the ASVH of any and all changes in my income and/or assets. I willobey the rules and regulations prescribed for the ASVH.I hereby authorize the ASVH to obtain all medical records from my physician, hospital,clinic or nursing home pertaining to my potential admission to the facility. These recordsmay include, but are not limited to, diagnostic/laboratory results, consultant and progressnotes/reports, assessment tools/reports, readmission screening documents, documentationfor Medicare benefits and any other items specified by the ASVH.Signature of Applicant or Legal RepresentativeDateAdmission shall be in accordance with Title VI of the Civil Rights Act of 1964 as amended;Section 504 Rehabilitation Act of 1973 as amended; the Age Discrimination Act of 1975; theAge Discrimination Act of 1967; the American’s with Disabilities Act of 1990; and ArizonaAdministrative Code Title 4 Charter 40.11

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONSECTION BThe following information is required to process your application for admission to theArizona State Veteran Home. If this information is incomplete, it will delay consideration of yourapplication. If questions are not applicable, please indicate with the abbreviation “N/A”.Information submitted is subject to verification. The Arizona State Veteran Home reserves theright to request verification of any funds received by copies of award forms or award letters.APPLICANT’S NAMEDATEAPPLICANT’S SOCIAL SECURITY #SPOUSE’S SOCIAL SECURITY #A. MONTHLY INCOMEVETERANSocial Security BenefitsU.S. Civil Service benefits (annuitynumber)U.S. Railroad retirement (number)Military RetirementMilitary RetirementV.A. Awards (type)State Retirement CompanyRetirementPrivate RetirementBlack LungBenefitSSI/Public AssistanceTotal Wages TotalDividends Total InterestOther (specify source):Total Monthly Income12SPOUSE

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONB. EXPENDITURESMedicare B Premium (per month)ALTCS Share of Cost (per month)C. ONE TIME INCOME IN THE PAST 12 MONTHSType:Amount:Type:Amount:D. NET WORTH (Excluding Home and Auto)CashBank AccountCD’sMillers TrustSavingsRevocable TrustNET WORTH TOTALSE. MEDICAL EXPENSES NOT REIMBURSED LAST YEARSigning below certifies that the above information is complete and correct. Authorization is given toverify any information provided herein.SignatureDate13Relationship

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONSECTION CPHYSICIAN’S CERTIFICATIONThe following information is to be completed and signed by the applicant’s physician. Thiscertification is valid for 6 months from the date of completion. All information must be current andcomplete to avoid delays in processing. Please attach a copy of the patient’s current (completedwithin the last 3 months) History and Physical (H&P) as well as a current TB test. Medications mustbe listed on this form or supplemented with a typed medication list that is signed by the physician.1. Name of Applicant:2. Date of Birth:3. Is this person capable of caring for him/herself?YesNo4. Patients current diagnosis:5. Applicant’s current medications:MedicationDoseFrequency (x per day)13DX for Medication

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION1. Diet and Diet Consistency:2. Activity Orders/Limitations:3. Are special treatments or therapies required for this person?YesNo4. Could this person be considered a danger to self or others?YesNoIf yes, please explain:5. Have they had a Mantoux TB skin test done in the past 6 months?If yes, please attach a copy of the resultsYes6. Has this person had Pneumovax 23?YesNoDate:7. Has this person had Pneumovax 14?YesNoDate:No8. Allergies?9. Is it your opinion that this applicant is in need of 24-hour nursing care?10. Both doses of the COVID-19 vaccine?YesYesNoNo11. If only one dose, which one and when?12. Please print or type the following:(Physicians nameAddress)Telephone numberCityStateZipPlease return this statement to the Arizona State Veteran Home with a copy of the patient'shistory, physical and TB test results.Physicians signatureDate14

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONSECTION DFUNCTIONAL ASSESSMENTFor each area of functioning listed below, please describe to the best of your ability the amount andtype of assistance the applicant currently requires.BATHINGDoes the applicant take a:ShowerTub bathSponge bathHow often does the applicant bathe?How much assistance is required?DRESSINGHow much assistance does the applicant receive in dressing (including selecting and getting clothesfrom the closet, putting on undergarments and using fasteners)?TOILETINGDoes the applicant require assistance with toileting (including getting to and from the bathroom,cleaning self after elimination and arranging clothes)?If yes, how much assistance is needed?Does the applicant have a catheter? YesDoes the applicant have a colostomy? YesNoIf yes, what type?NoIs the applicant able to control urination?Bowel movements?If no, how often do “accidents” occur?MOBILITYDoes the applicant walk (list assistive devices used) or do they use a wheelchair?Does the applicant need assistance getting out of bed or a chair?If yes, how much assistance is needed?15YesNo

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONEATINGDoes the applicant feed themselves or require assistance?Does the applicant use adaptive equipment while eating (plate guard, special spoon, etc )?YesNoIf yes, describe the type and frequencyIs the applicant on a special diet?How would you describe the applicant’s appetite?HeightWeightPROSTHESESDoes the applicant have an arm or leg prosthesis?Does the applicant wear dentures (upper and lower)?Does the applicant use hearing aid(s)?SKINDoes the applicant presently have pressure sores (if yes, where are they and how long)?Does the applicant have skin rashes?Does the applicant experience swelling of the legs and/or feet?16

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONORIENTATIONIs the applicant alert and oriented or do they exhibit confusion? (If confused, is it ongoing,often, or occasional?)For individuals who are confused and disoriented:Does the applicant attempt to wander?YesNoIf yes, how often?Is the applicant willing to return if given direction?OTHER HEALTH CONSIDERATIONSDoes the applicant currently use physical or chemical restraints?If yes, describe the type and frequencyHas the applicant been hospitalized or are they currently being treated for mental health problems?If yes, describe the type and frequencyDoes the applicant maintain active and satisfying relationships with family and friends?17

ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSIONDoes the applicant have a history of drug and/or alcohol abuse?YesNoIf yes, please describe:Is the applicant an active smoker?If yes, are they considered safe?YesNoYesNoIs the applicant currently receiving physical, occupational, speech, or respiratory therapy? Ifyes, list the type of therapy, reason, and frequency the therapy is received:ADDITIONAL INFORMATION:18 Arizona Department of Veterans’ Services. All rights reserved. (rev.2021-12-27.pia)

Dec 27, 2021 · ARIZONA STATE VETERAN HOME APPLICATION FOR ADMISSION 4 Mission Statement: The mission of the Arizona State Veteran Homes is to provide professional skilled nursing and rehabilitative care for the geriatric and chronically ill Veteran and dependent/surviving spouses throughout the St