APPLICANT ADMISSION CHECKLIST
WVH–Chippewa Falls

2175 E. Park Ave.

Chippewa Falls, WI 54729

(715) 720-6775
Toll-free Fax (888) 966-8821	WVH–King

N2665 County Rd. QQ

King, WI 54946-0600

(715) 258-5586
Toll-free Fax (888) 966-8819	WVH–Union Grove

21425 G Spring St.

Union Grove, WI 53182

(262) 878-6702
Toll-free Fax (888) 966-8816
PLEASE SUBMIT COPIES OF ALL APPLICABLE DOCUMENTS WITH YOUR APPLICATION:

WDVA 4000 – Application for Admission to Wisconsin Veterans Home (WVH): Basic applicant information.

WDVA 4002 – Authorization for Disclosure of Health Information: Authorizes WVH to contact physicians, psychologists, hospitals, nursing homes and other facilities that have provided you with care.

Military Separation Orders or Discharge Papers (DD214 or similar document): Confirms veteran’s eligibility with dates of military service, discharge status and state where veteran entered service; an honorable discharge is required; can be obtained through County Veterans Service Office (CVSO), in the county where the veteran resides, or you can call the Home’s number listed above, and we can check our database for you.

Service-Connected Disability Award Letter from VA.

Birth Information – Certified copy of the applicant’s Birth Certificate OR other acceptable evidence relating to the applicant’s birth; acceptable documents may include but are not limited to a government issued marriage license, government issued death certificate, divorce decree, government issued driver’s license, government issued identification, or government issued passport or passport card.

Copy of front and back of all Health Insurance cards.

Certified copy of Marriage Certificate if applicant is a spouse/surviving spouse of veteran.

Certified copy of Death Certificate of veteran if applicant is a surviving spouse of veteran.

IF YOU ALREADY HAVE THE FOLLOWING DOCUMENTS COMPLETED, PLEASE SUBMIT A COPY WITH YOUR APPLICATION:

Power of Attorney for Health Care (POAHC): This document allows you to designate an agent, to act on your behalf, in health care matters, should you ever become incapacitated.

Power of Attorney for Finances (POAF): This document allows you to designate an agent, to act on your behalf, in financial matters. You can choose to make this document active at any time.

Statement of Incapacity: This Statement is signed by 2 physicians, or a physician and a psychologist, who have determined the person to no longer be able to effectively make their own health care decisions, and “activates” the POAHC.

Living Will/Trust

Guardianships: Include a copy of the Guardianship of Person and/or Estate court orders.

Protective Placement: Include a copy of Protective Placement court order allowing admission.

ASSISTED LIVING – UNION GROVE:

Bank statements for the last 2 months.

Documentation to verify assets.

(Assisted Living applicants must have sufficient income and assets to fund two years of residency.)

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WDVA 4006 (02/16)	You can access the most recent version of this form

Templates\WDVA_4006-WVH-Applicant-Admissions-Checklist.dot	from the WDVA website at www.WisVets.com/Forms.

WDVA 4006 - Applicant Admission Checklist

Formerly WDVA 5001

Karen Emery

2013-05-08

Jacobs, Pam

Department of Veterans Affairs