Admission Application

Application forms are available on our website in two formats -- Microsoft Word fillable format (you can access, complete, and print from your computer) and Adobe Acrobat PDF format (print from your computer, complete by hand).

Your County Veterans Service Office also can answer eligibility questions and help with the application process.

To arrange for a pre-admission tour call:

• Veterans Home at King at (715) 258-5586 ext. 2270
• Veterans Home at Union Grove at (262) 878-6700 ext. 6749 or (866) NOW-VETS (866-669-8387)

Eligibility & Residency Requirements

To be admitted to the Home, veterans must meet criteria for military service and state residency.

The veteran must have entered service from the state of Wisconsin, or must have resided in the state of Wisconsin for 12 consecutive months since his/her discharge from military service. The application form must reflect a Wisconsin address for the home address. A spouse of a veteran can also reside at the Wisconsin Veterans Home, provided they are admitted while the veteran is at some type of facility (i.e. assisted living, nursing home, hospital) or if the spouse is a widow/widower.

Admission Forms Left click an icon below in the Format column to open the file Right click an icon below to save the file to your computer
= Adobe format	= Apply online
= fillable Word 97 format

	Wisconsin Veterans Homes Forms
Form #	Form Title / Revision Date	Format
DDE 2191	Wis. Dept. of Health Services – Preadmission Screen & Resident Review (PASARR) – Level 1 Screen
VA 10-10EZ	Application for Health Benefits (11/09)
VA 10-5345	Request for and Authorization to Release Medical Records or Health Information (05/05)
WDVA 1805	Veteran's Residency Affidavit (07/10)
WDVA 4000	Application for Admission to the Wisconsin Veterans Home (03/11)
WDVA 4001	Applicant's Financial Statement (03/11)
WDVA 4002	Authorization for Disclosure of Health Information (03/11)
WDVA 4004	Medical Care Determination (03/11)
WDVA 4006	Applicant Admissions Checklist – Wisconsin Veterans Homes (03/11)
WDVA 4020F	Admission Agreement – Attachment F – Privacy Practices (03/11)
WDVA B0215	Wisconsin Veterans Home at Union Grove (06/07) (Daily Care Rates page revised 01/10)
WDVA B3401	Wisconsin Veterans Home at King – Caring for America's Heroes (01/12)
WDVA P4015	Wisconsin Veterans Homes – Wonderful places to live! (10/10)

Wisconsin Veterans Homes