ELIGIBILITY REQUIREMENTS

Non-Medical

The Applicant:

• Must be a resident of Maryland
   

• Must have an honorable discharge from the Armed Forces of the United States (Army, Navy, Air Force, Marines and/or Coast Guard)
   

• Certain Non-veteran spouses of veterans eligible to be admitted to Charlotte Hall.
   

• If under the age of 62, must have a disability recognized by either the Veterans Administration or the Social Security Administration that renders the applicant incapable of earning a living by reason of age, disease or disability.
   

• May not have criminal charges pending or be under lawful detainer.

• Charlotte Hall may deny admission to an applicant, if that admission could prove a risk to the health, safety or welfare of any other Resident or individual associated with the facility.
   

• The applicant must not be mentally ill or dangerous to himself or others.
   

• If previously dependent on alcohol and/or other substances, the applicant must have successfully completed a structured rehabilitative program prior to admission. After successful completion of such a program, we offer/require continuing sobriety maintenance through the help of our trained staff.
   

• The applicant must have a chest x-ray prior to admission to rule out the presence of tuberculosis. If the applicant is coming from home or a hospital, the chest x-ray must be dated within 30 days of admission. If the applicant is coming from another long-term care facility, the chest x-ray must be dated within 6 months.

DOCUMENTATION REQUIRED BEFORE ADMISSION

• Proof of Maryland residency
   

• Proof of honorable discharge (DD2 14 or equivalent)*
   

• Proof of disability if under age 62.
  
  *If the applicant does not have a copy of his DD2 14, the applicant may get a copy of the form to request the document. It takes approximately 6 weeks to receive the new DD2 14.
   

• Have the applicant's personal physician complete the medical forms necessary for admission. If the applicant has been hospitalized, the applicant needs to supply his medical records from the hospital.
   

• Proof of income
   

• Application packet

• The applicant must have a complete physical verifying that he has the mental and physical ability to perform the following:
   

• Perform routine and daily personal functions - dress and feed himself make his own bed and keep his room clean.
   

• Make his way to and from the first floor dining area.
   

• Control body eliminations (either naturally or by prosthesis).
   

• Make rational and competent decisions as to the desire to remain or leave Charlotte Hall
   

• Advance Directive

• The applicant must have his physician verify that he does not require medical, surgical and nursing care beyond the capabilities of the facility.
   

• If the applicant is admitted directly from a long-term health care facility, please provide the following information:
   

• Current medical findings
   

• Diagnosis and prognosis
   

• Medical rehabilitation goals
   

• A summary of the course of treatment followed in the hospital or other health care facility
   

• Physician orders for your immediate care
   

• If the applicant moves to Charlotte Hall directly from home, please supply the following medical information:
   

  • Current (within 30 days) medical findings
     

  • Diagnosis and Prognosis
     

  • Medical rehabilitation goals
     

  • Physician orders for your immediate care
     

• Advance Directive

• To qualify for admission to our Alzheimer's Unit, the applicant must meet all of the following criteria:

• Have a diagnosis of Alzheimer's disease or related dementia as confirmed by his personal physician.

• Require the security of a locked medical unit to prevent wandering

• Require limited assistance in ADL function with direct supervision and assistance
   

• Be capable of participating in the activities on this Special Care Unit

Admission Paperwork Checklist

• DD214
   

• Proof of Residency
   

• Proof of disability if under age 62.
   

• Income Verification (award letter, bank statement)
   

• Application
   

• Past Life Social History
   

• Financial Questionnaire (Long-term Care)
   

• Assisted Living Resident Income Disclosure Form (Assisted Living)
   

• VAForm10-10EZ
   

• Copy of insurance cards
   

• Copy of Power of Attorney and/or Living Will, and Advance Directive
   

• Assisted Living Residents who wish to have a vehicle at Charlotte Hall must complete an application for vehicle registration.

  • Valid Maryland Drivers License

  • Valid Maryland Vehicle Registration

  • Proof of Insurance

For Physician

• "Physician Certification Related to Medical Condition" Form
   

• Healthcare Practitioner's Physical Assessment (Assisted Living only) Form 4506
   

• Maryland Medical Assistance Medical Eligibility Review Form (Long-term Care only) Form 3871
   

• VAForm10-10SH
   

• Department of Health and Mental Hygiene ID Screen (Long-term Care only) Form 4345
   

• Physicians Orders for your immediate care (Long-term Care only)
   

• Chest X-ray

***All medical Forms must be dated within 30 days of admission date***

Send your completed application to:

Admissions Coordinator
Charlotte Hall Veterans Home
29449 Charlotte Hall Road
Charlotte Hall, Maryland 20622
Telephone (301) 884-8171 or 1-800-522-VETS - Extension 1409#
admissions@charhall.org

Website by: SBVisions

Last updated: October 31, 2007