Application for Admission

Thank you for your interest in the Arizona Pioneers’ Home!

Please visit our Admissions page to view the Arizona Revised Statutes, which explains the requirements for residency here at the Home. If you feel that you or your loved one meets the qualifications of a Pioneer or a Miner, please keep scrolling to read the explanation of the Welcome Guide and the Application for Admission. The next stop is the Frequently Asked Questions page! In an effort to make this process as simple as possible, we have recently changed the format of our Application and the Welcome Guides.

Welcome!

There are two Welcome Guides: one for Pioneers and Independent Miners, and one for Dependent Miners.

Pioneers and Independent Miners: (1st and 3rd floors)
- ALL Pioneers will be Independent, as they must be able to live without assistance of any kind (except for medications) for the first 60 days of residency.
- Miners (physically disabled or qualifying financially) can live on an independent floor if they do not need assistance.
Dependent Miners: (2nd floor, North and South Infirmaries)
- Miners (both physically disabled or qualifying financially) who need assistance with Activities of Daily Living or are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.
- The infirmaries are also open to Pioneers, but after they complete their 60-Day Adjustment Period upon admission, completely independent.

Please note: The explanation of how the Pioneers’ Home defines independence is the 2nd question on the Frequently Asked Questions page of our website, and is also in the Welcome Guide. Our Director of Nursing and our Superintendent will make the final determination of placement.

The Welcome Guides give you a sneak peek in to life at the Pioneers’ Home! They include:

Arizona Revised Statues stating the qualifications for residency
Frequently Asked Questions
Application for Admission explanation, which includes which Qualifying Document packet you need
- Qualifying Documents for Pioneers
- Qualifying Documents for Physically Disabled Miners
- Qualifying Documents for Miners Qualifying Financially
Chart of allowed and not allowed items
Arizona Pioneers’ Home TV Channel Guide

You may download the Welcome Guides here by clicking on Pioneers and Independent Miners or Dependent Miners...or to request one by mail or for pick-up, call our Administrative Services office at 928-277-2721.

As mentioned above, we re-formatted the Application for Admission…we hope the update makes the Admission process as easy as possible. In case you were wondering, the forms have not changed, just how they are arranged is different…and it goes like this:

Start with the Application for Admission: It is now one application that includes everything that both Pioneers’ and Miners need to complete.
Next, our Administrative Services office can help determine which of the following you need based on your qualifications. Each Qualifying Documents packet only has information and forms that pertain to each group:
Healthcare and Financial Directives packet: If you already have your directives written up then you will not need these documents. If you do NOT have them written, ask our staff for the Healthcare and Financial Directives packet which contains all the forms you need, which are as follows.
- Healthcare Power of Attorney
- Mental Health Power of Attorney
- Financial Power of Attorney (General Power of Attorney)
- Living Will
- Do not resuscitate (DNR) or Full Code.

As always, if you have questions or wish to request an Application for Admission, please call our Administrative Services office at 928-277-2721.

What is in the Application for Admission?

The Application for Admission includes all documents that apply to both Pioneers and Miners. There are a few documents that only pertain to each status so they are in separate packets. Once it is determined which you qualify for, you will receive the appropriate packet.

Medical Record Requests: Our staff will request all records from every provider you have seen in the last two years.
Required Healthcare Provider Documents: The applicant will need an appointment for a physical with their primary medical provider, and also an eye doctor and dentist appointment. There are four pages for your primary medical provider to fill out, and one page each for both your eye doctor and your dentist.
Healthcare and Financial Directives: The Home requires that each applicant/resident have the following directives: Healthcare, Mental Health, Financial, Living Will and either a DNR or a Full Code. We can offer these forms to fill out if you don’t already have them.
Additional Required Documents: Seven forms that cover everything else!
Consumer Report: Pursuant to A.R.S. 41-923(A, C) and in connection with your application for residency, we need to procure certain background information concerning you which is contained in a consumer report. You have the right to decline authorization for us to procure a consumer report. However, we will not consider you further for residency if you so decline.

Both Pioneers and Miners will need to supply copies of:

The following cards, front and back
- Social Security Card
- Arizona Driver's License/Arizona Photo ID
- Veteran’s ID (if applicable)
- Medicare card (if applicable)
- Supplement insurance card (if applicable)
- Medicare Part “D” insurance card (if applicable)
- Advantage Plan insurance card (if applicable)
- AHCCCS card (if applicable)
Healthcare and Financial Directives –If you don’t already have these documents filled out and signed by your designated Resident Representative(s), you can ask our staff for
- Healthcare Power of Attorney
- Mental Health Power of Attorney
- Financial Power of Attorney (General Power of Attorney)
- Living Will
- DNR or FULL Code (You must choose one OR the other, do not fill out both.)

Insurance Requirements for both Pioneers and Miners

A resident must maintain either VA coverage, OR, Medicare Parts A & B and a supplemental plan that has a separate Medicare Part D plan, OR Medicare Parts A & B and AHCCCS coverage, OR an Advantage plan that includes Medicare Part D (Drug plan). All insurance coverage must be valid in Yavapai County.
A resident is required to maintain insurance coverage that covers the cost of prescription medication. If medication is not covered by VA or AHCCCS, the resident must maintain a Medicare Part D insurance policy while they are a resident of the Arizona Pioneers’ Home. This must be either in a standalone Part D policy or part of an Advantage plan.

Miner's Qualifying Document Packets

There are two packets for Miners depending on your qualification for residency: Physically Disabled Miner, and Miner Qualifying Financially.

Those packets include:

Physically Disabled Miner
- Disabled Miner Physicians Certificate
- Affidavit of Mining Employment (must be notarized)
Miner Qualifying Financially
- Miner’s Financial Attestation
- Affidavit of Mining Employment (must be notarized)

Pioneer’s Qualifying Documents Packet

Forms that only pertain to Pioneers include:

Defining Independence
Resident Statement (must be notarized)
Resident Financial Disclosure (see the next section for requested documents)

Final Thoughts

Before we can offer an interview, we will need the applicant’s most recent two years of medical records. If you turn in the Authorization for Disclosure of Health Information and the Medical Provider List right away, we can start requesting medical records that may take some time to receive.

Our staff will review the completed application and the medical records to determine if an interview can be offered. If offered, after the interview, payment for the above referenced consumer report will be due and the report will be run ($64.50 non-refundable, make check payable to Arizona Pioneers’ Home). This consumer report is for resident screening purposes only, and is strictly confidential. Once we receive the report we will be in touch with a decision.

And that’s it! All in less than 90 Days (per Assisted Living licensing regulations).