Form 49028

DISCLOSURE FOR HOUSING WITH SERVICES ESTABLISHMENTS

State Form 49028 (R3 / 7-11)

Date received stamp (month, day, year)

The Disclosure for Housing with Services Establishments form is to be submitted to comply with IC 12-10-15. All sections, except Section 8, Optional Information,

shall be fully completed. Section 8 is optional and provides information that you may wish to answer for potential residents who may use this form when looking

for services.

A copy of the contract to be executed between the Housing with Services Establishment and the resident is the ONLY attachment that will be accepted in

addition to the disclosure form. Therefore, it is important to concisely answer the questions on the form.

Original Year ________\________\________ Update Year ________\________\________ Renewal Year ________\________\________

Indicate whether this is an original, update, or a renewal and enter date:

SECTION 1 - ESTABLISHMENT INFORMATION

Name of facility

On site manager's name

Address line 1 (number and street)

Address line 2 (number and street)

City

Telephone number

County

Fax number

ZIP code

E-mail address

Capacity (number of apartments)

Is the facility licensed as a residential care facility by the Indiana State

Department of Health?

Does the facility participate in the Residential Care Assistance Program

(RBA/ARCH)?

Is your facility structure (select one):

freestanding?

part of a campus or complex? (select all that apply)

part of an independent apartment complex?

part of a nursing facility?

part of an independent living building?

part of a hospital?

part of a continuing care facility?

other: _____________________________

If Yes, license number

If Yes, enter the 4 digit ID

Yes No

Name of owner/company

DBA

Address line 1 (number and street)

Address line 2 (number and street)

City

Telephone number

SECTION 2 - OWNERSHIP / TYPE OF BUSINESS INFORMATION

State

Fax number

ZIP code

E-mail address

Name of managing agent (if not owner)

Address line 1 (number and street)

Address line 2 (number and street)

City

Telephone number

State

Fax number

ZIP code

E-mail address

Type of business (select one):

Business ownership (select one):

Month of the year that begins your fiscal (accounting) year?

For Profit Not For Profit Government

Sole Owner Partnership Corporation

Other (please indicate)

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Is the facility an Assisted Living Medicaid Waiver provider?

Yes No

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Facility Employer Identification Number (EIN)

Reset Form

SECTION 3 - CORPORATE OFFICERS

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

SECTION 4 - MEMBERS OF GOVERNING BODY/ CORPORATE DIRECTORS

Name

Title

Address line 1 (number and street)

City

Telephone number:

ZIP code:

State:

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

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SECTION 4 - MEMBERS OF GOVERNING BODY/ CORPORATE DIRECTORS (continued)

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

Name

Title

Address line 1 (number and street)

City

Telephone number

ZIP code

State

SECTION 5 - BASE RATE

Normal length of lease (contract):

1 month 3 months 6 months 1 year

Other:

MONTHLY Per Person Base Rate Ranges for all that apply:

(Note: If you convert a daily rate to a monthly rate please

multiply your daily rate by 365 and then divide by 12.)

Studio

One Bedroom

Two Bedroom

From: $ _________________________ To: $ ________________________

Yes No Yes No Optional

Semi-Private

Occupancy:

Kitchenette:

Yes No Yes No Optional

Additional fees may be required (examples - admission fee, deposit fee, buy in fee, etc.)

Additional:______________________________________________________________________________________________________

SECTION 6 - CONTRACT INFORMATION

What is the criteria and process used to determine who may continue to reside in your facility?

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Can the contract be modified or terminated by the facility? Yes No If Yes, please explain under what conditions and the referral process.

SECTION 6 - CONTRACT INFORMATION (continued)

Can the contract be modified or terminated by the resident? Yes No If Yes, please explain under what conditions and the referral process.

Outline the steps that should be taken by the resident to register a complaint and the process for resolving the complaints.

SECTION 7 - SERVICES INCLUDED IN THE BASE RATE AND / OR AVAILABLE FOR AN ADDITIONAL FEE (check all that apply)

MEALS:

Breakfast:

Lunch:

Dinner:

Snacks:

Included

Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

HOUSEKEEPING:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

LAUNDRY:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Bed/Bath Linens:

Personal:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

PERSONAL ASSISTANCE:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Extra personal assistance fees are per:

Dressing:

Toileting:

Transferring:

Mobility:

Bathing:

Eating:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

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Month Bi-Week Week Day Other

Extra meal fees are per:

Month Bi-Week Week Day OtherExtra housekeeping fees are per:

Month Bi-Week Week Day OtherExtra laundry fees are per:

Month Bi-Week Week Day Other

SECTION 7 - SERVICES INCLUDED IN THE BASE RATE AND / OR AVAILABLE FOR AN ADDITIONAL FEE (cont.) (check all that apply)

BLOOD PRESSURE TAKEN:

Included

Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Extra blood pressure fees are per: Month Bi-Week Week Day Other

Comments:

EMERGENCY RESPONSE SYSTEM (ERS):

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Extra "ERS" fees are per: Month Bi-Week Week Day Other

Comments:

24-HOUR NURSING RESPONSE:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Extra 24 hr. fees are per: Month Bi-Week Week Day Other

Comments:

LICENSED NURSING SERVICES AVAILABLE:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

MEDICATIONS:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Reminders:

Set-up:

Dispensing:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

ARRANGING OTHER MEDICAL SERVICES:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

ASSISTING WITH PERSONAL FUNDS:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

WANDER PROTECTION SYSTEM:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Month Bi-Week Week Day Other

Comments:

ACTIVITIES:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Day Outings:

In-House Activities:

Event Tickets:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

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Extra fund fees are per:

Extra wander fees are per:

Month Bi-Week Week Day Other

Extra medical fees are per: Month Bi-Week Week Day Other

Extra medication fees are per: Month Bi-Week Week Day Other

Extra fees are per: Month Bi-Week Week Day Other

Month Bi-Week Week Day OtherExtra activity fees are per:

TRANSPORTATION:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Facility Scheduled:

Unscheduled:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

SECTION 7 - SERVICES INCLUDED IN THE BASE RATE AND / OR AVAILABLE FOR AN ADDITIONAL FEE (con't.) (check all that apply)

Extra transportation fees are per:

UTILITIES:

Included

Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Heating:

Air Conditioning:

Electricity:

Water / Sewage:

Local Phone:

Cable TV:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Comments:

Services not listed on this form that are either included or available for an additional fee:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Service:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Service:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Service:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Service:

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Service:

Other Wellness / Health Related Services: Yes No If Yes, explain below:

SECTION 8 - OPTIONAL INFORMATION

Do you offer wheelchair accessible units and / or common areas (check all that apply)?

Yes No

Units / Apartments Common Areas

Does each apartment have fire sprinklers?

Are pets allowed?

Yes No

If Yes, please describe any additional fees or special conditions below:

Do you have a nursing home / health care center at the same location? Yes No

Are rehabilitation services available on site?

Yes No

If Yes, please identify:

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Month Bi-Week Week Day Other

Extra utilities fees are per:

Month Bi-Week Week Day Other

Included Not Included Extra Fee, From: $ _____________________ To: $ _____________________

Service:

SECTION 9 - INDIVIDUAL SUBMITTING THE DISCLOSURE / MAILING INSTRUCTIONS

Name of individual completing the form

Company / Affiliation

Address (number and street)

City, state, ZIP code

Telephone number

Verified by (name)

Verified by (signature)

Title

Fax number E-mail address

Title

Date (month, day, year)

Send the completed form to the following address: (Please do not FAX)

Disclosure for Housing with Services Establishments

FSSA Division of Aging

402 West Washington Street, Room W454, MS 21

Indianapolis, IN 46204

For question call: 1-888-673-0002

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DO NOT WRITE IN THIS SECTION

(For Official Use Only)

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Fillable Printable Form 49028

Fillable Printable Form 49028