Assisted Living Application

Showalter Center • 1060 Showalter Drive • Blacksburg, VA 24060 •(540)443-3415

This form must be completed all at once and cannot be saved to finish later. Please provide answers to all relevant questions on the following pages. If you have questions as you complete the forms, please call Linda Kirkner at 540-443-3415.

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Today's Date*
Month
Day
Year
SHOWALTER CENTER - Desired Accommodations*
- Studio
- 1 Bedroom
- 2 Bedroom
- Auxiliary Grant
- First Available
Name of Person Supplying Information*
Relationship to Applicant*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Phone 2
Email*

Financial Information
Medicare #
Medicaid #
Health Insurance Company
Phone
Health Insurance Policy #
How does the Applicant plan to finance care?
Monthly Income Information
Social Security
Retirement
Other (savings, interest)
Adequate Funds Available
For Three Years
- Yes
- No
Will provide financial documentation at time of admission
Has the Applicant applied for Medicaid?
- Yes
- No
If yes, complete the following
Social Security Dept. Name
Eligibility Worker
Who will be responsible for handling finances and billing?
Has a Durable Financial Power of Attorney been designated?
- Yes
- No
Name
Phone
Relationship to Applicant
Other Information
Pastor
Affiliation
Address
Phone
Mortuary Preference
Address
Phone
Any special donor arrangements?
List Applicant’s current and past interests and hobbies
Would Applicant show interest in involvement with Activities?
- Yes
- No
If so, what type of activities
Other information pertinent to application
Note: Prior to admission please provide the following documents- Social Security Card, Insurance Cards, POA/ guardianship Documents, Advance Medical Directives and DNR orders

Warm Hearth Village (WHV) strives to maintain a safe environment for all residents, visitors and staff by requiring a criminal background check prior to long-term residency effective May 1, 2016. A national criminal background check will be obtained for each applicant seeking residency at WHV regardless of level of care/service. WHV, via the admissions committee, will review the results of the background check and compare the results with the Department of Health "barrier crime” list. Applicants can be denied admission based on the number and severity of convictions listed on the background check. Any negative findings may be grounds for dismissal from care and services and/or denial of long-term residency. Applicants denied admission to WHV will be provided with a form stating the reason for the denial and a copy of the background check. Residents/clients denied admission to WHV may appeal by presenting a letter of request to the applicable Administrator/Director.
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Apply to Assisted Living

Step 1 of 4

In Case of Emergency Notify:

Names, Addresses and Telephone Numbers of all living children:

Medical Information

Financial Information

Monthly Income Information

If yes, complete the following

Other Information