II. Responsible Party/Emergency Contacts:

VestraCare requests that to the greatest extent feasible, the individual named as the Financial/Designated Representative for the applicant to be an existing attorney-in-fact for the applicant, or be granted a Durable Power of Attorney by the applicant as soon as possible to ensure continuity of payment of all expenses incurred to the extent of the applicant's resources.

A. Advanced Directives:

B. Financial/Designated Representative (manages finances for applicant)

C. Emergency Contact

III. Insurance Coverage:

Other Medical Insurance (BC/BC, IHA, HCP, Univera, EPIC, No Fault)

Provide copies of all Insurance, Medicare, Pharmacy & Social Security cards

IV. Statement of Income:

V. Assets / Resources:

Additional Assets / Resources - Applicant or Joint with Applicant - (Checking, Savings, CDs,stocks, bonds, annuities, money market, etc.)

VI. Liabilities:

VII. Divesting:

VIII. Counsel:

REPRESENTATIONS, WARRANTIES AND INDEMNIFICATION AGREEMENT

1. Upon satisfactory review of the Questionnaire, including the representations and warranties made herein, VestraCare will consider the Resident for admission.




2. The Resident and Representative each acknowledge Vestracare’s reliance on the statements made by them in the Admission Questionnaire and the promises made herein and agree to indemnify and hold Vestracare harmless from any and all liability, loss, expense, and/or damage which Vestracare may incur by reason of any misrepresentation contained in either document or their noncompliance with either document.




3. The Resident and Representative represent and warrant to Vestracare that the Resident’s assets are fully and accurately disclosed on the Questionnaire and that there have been no transfers of the Resident’s ownership interest in any assets or resources within the past 60 months for which fair payment has not been received other than those listed in section VII?




4. The Resident and Representative agree that neither of them has previously done anything nor will either of them at any time hereafter do anything that would cause the Resident to become ineligible or disqualified for Medicaid for any period of time whether by reason of having transferred the Resident’s present or future acquired assets without
   receiving fair payment or value in exchange for such transfer or otherwise.




5. If the Resident is the owner of a residence, the Resident and Representative represent and warrant that if and when the Resident no longer intends to return to such residence, such residence will be promptly sold for fair value and the proceeds used to discharge Resident’s obligations to Vestracare if and when other resources are exhausted. Prior to exhausting Resident’s other assets, they will list the residence for sale (with an M-L broker) for its then fair market value and diligently pursue the closing of a sale of the residence. The proceeds of sale will be held and used solely for discharging Resident’s legal obligations, including the obligations to Vestracare.




6. The Resident and Representative agree that prior to exhausting the Resident’s assets and resources, they will make timely application for Medicaid. The application shall be made in such manner and at such time that the Resident will be able to pay his/her obligations to Vestracare by means of the Resident’s assets and resources and/or medical assistance provided by the State of New York or other government agency.




7. If the Resident is denied timely Medicaid coverage due to the willful or negligent failure of Resident and/or Representative to abide by this Agreement, they agree to indemnify and hold Vestracare harmless of and from any and all loss or damage occasioned by any misrepresentation or failure to qualify for Medicaid and they each agree to pay and reimburse Vestracare unconditionally all amounts that Vestracare would have received had a timely Medicaid pick-up date occurred.




8. The liability of the Resident and the Representative for all damages incurred by Vestracare as a result of the breach by either of them of any of the covenants and representations made herein will be joint and several. Nothing herein, however, shall be construed to be a personal guaranty by the Representative of the obligations of the Resident to Vestracare for the room, board and/or care provided to Resident at Vestracare except to the extent that such obligation arises as a result of a breach of the covenants made herein.