Free Nursing Home Affidavit of Financial Status

STATE OF [Your State]

COUNTY OF [Your County]

I, [Your Name], of legal age, and currently the [Your Job Title] at [Your Company Name], located at [Your Company Address], being duly sworn, depose and say:

1. Provider Authority and Facility Details:

As the [Your Job Title] at [Your Company Name], I am authorized to access and disclose financial information in accordance with state and federal regulations. Our facility adheres to strict privacy policies to protect all personal and financial data of our residents.

2. Resident Identification and Admission Details:

I hereby certify that [Your Client Name], who was admitted to our facility on [Admission Date], has maintained a status of good standing throughout their residency. This affidavit provides a comprehensive overview of the financial commitments associated with their care at [Your Company Name], ensuring transparency and accountability in our financial dealings with the resident.

• Admission Verification: Confirmation of the date and conditions under which [Your Client Name] was admitted into our facility.

• Residency Status: Ongoing evaluation of the resident’s compliance with the facility's policies and their engagement with offered services.

• Record Maintenance: Detailing the meticulous upkeep of all administrative and care records pertaining to [Your Client Name], ensuring accuracy and accessibility for all required purposes.

3. Financial Arrangements and Status:

The financial framework supporting the care of [Your Client Name] at [Your Company Name] is structured to ensure all costs are transparently and effectively managed. The details are as follows:

• Source of Income:

  • Description: Comprehensive details of all income sources for [Your Client Name], including pensions, Social Security benefits, private investments, and other relevant income streams that contribute to covering the costs of care.

  • Verification: Regular verification of income sources to ensure continued funding for care services and to adjust financial planning as necessary.

• Insurance Coverage:

  • Policy Details: Detailed description of all health insurance policies held by the resident, including coverage provided by Medicaid/Medicare if applicable.

  • Benefit Utilization: Explanation of how benefits are applied to medical and care-related expenses, ensuring optimal use of available insurance resources.

• Monthly Fees and Charges:

  • Breakdown: A detailed breakdown of monthly care fees, which include accommodation, basic medical care, and any personalized services.

  • Additional Charges: Documentation of any additional service charges or incidental expenses that arise outside of the regular care package.

• Payment Record:

  • Payment Tracking: A thorough summary of all payments received up to the date of this affidavit, alongside any outstanding balances.

  • Financial Accountability: Regular updates to the payment record to reflect any new charges or payments, ensuring ongoing financial transparency.

4. Purpose of Financial Documentation:

This affidavit is prepared to affirm the financial status of [Your Client Name] for purposes including, but not limited to, eligibility for financial aid, benefits applications, or family and legal representative inquiries regarding financial obligations and status.

5. Verification of Financial Records:

The financial information presented herein has been verified against our records, maintained securely at [Your Company Name]. These records are subject to audit and verification by authorized external parties, under the guidelines of our facility's compliance with financial reporting requirements.

6. Compliance and Confidentiality:

I affirm that all financial disclosures made in this affidavit comply with applicable financial reporting standards and privacy laws. The information is disclosed solely for the purposes stated herein and with the consent of [Your Client Name] or their legal representative.

7. Execution:

This affidavit is executed to provide an accurate and lawful declaration of the financial status of [Your Client Name]. It serves as a critical document to support the financial management and planning related to their care at our facility.

SWORN TO AND SUBSCRIBED before me this [Month Day, Year].

[Your Job Title]

[Your Company Name]

Notary Public:

State of [Your State]

My commission expires [MM-DD-YYYY].

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