Introduction
Thank you for your interest in the Arizona Pioneers’ Home!
Please visit the Admissions page to view the Arizona Revised Statutes that explain the requirements for who qualifies to live 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 Admissions Application and then visit the Frequently Asked Questions page. You can also find all of this information in our Introduction.
Pioneer: If you feel you qualify as a Pioneer, feel free to download and print the Pioneers Application for Admission, or call our Administrative Services office to arrange to receive a copy. (Updated September 2022)
Disabled Miner: We have a separate application for those who qualify as a Miner. If you worked as a miner in the state of Arizona, please call to find out if you qualify, and to ask for the application.
Before we can offer an Admissions Meeting, we will need your most recent two years of medical records, which our staff will request for you.
Our staff will review the completed application and the medical records and determine if an Admissions Meeting can be offered. If offered, after the Admissions Meeting, payment for the above referenced consumer report ($64.50 non-refundable) will be due and the report will be run. 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).
If you have questions or wish to request an Admissions Application, please call Administrative Services at the Arizona Pioneers’ Home 928-277-2721.
Summary of the Admissions Application
· 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 the applicant 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.
ü A.R.S. 41-923(A) A person of good character is eligible to be admitted to the Arizona Pioneers' Home.
ü A.R.S. 41-923(C) The superintendent may admit a person to the home when a full examination and investigation reveal that the person possesses the qualifications prescribed by this section.
· The applicant will need an appointment with his/her primary medical provider, to have the following filled out (by the medical provider) and returned with the application.
o 90 Day Determination - The Arizona Administrative Code section R9-10-807 requires that they submit documentation of determination of their level of care that is dated within 90 calendar days before they are accepted by an assisted living facility
o Disabled Miner Physician’s Certificate (Miners only)
o History & Physical
o TB Test/COVID-19 Vaccine Information
ü TB: Documentation must be from a licensed health care provider in the form of a tuberculin (TB) test or chest x-ray that is no older than 12 months.
ü COVID-19: Before admission please disclose your COVID-19 vaccine status, and provide your CDC COVID-19 Vaccination Record Card if you have received the vaccine.
- At this time, you will also need to schedule an eye exam, and a dental exam (regardless if you have dentures). The following are Arizona Pioneers’ Home forms that must be filled out and returned:
o Pre-Admission Eye Examination
o Pre-Admission Dental Examination
ü Dental: Any pre-existing issues will be the sole responsibility of the resident. Once admitted, the Arizona Pioneers’ Home will pay half of each dental bill, not related to a pre-existing issue, until the $1,000 lifetime maximum is reached.
ü Eye: Once admitted, the Arizona Pioneers’ Home will split the cost 50/50 up to $150 for costs incurred for a vision exam and when a change of prescription warrants replacement.
ü There is a waiver that can be signed in the event that a pre-admission eye or dental exam cannot be completed or you choose not to complete one. It states the following:” I acknowledge that I have not provided a Pre-Admission Exam to the Arizona Pioneers’ Home prior to my admission on ___. Therefore, by signing below I accept full responsibility for any and all expenses I incur after admission until such time that I have an exam to establish a baseline of any pre-existing conditions. It will not be until that time that I may participate in the Home’s 50/50 payment of care expenses I incur that are not pre-existing, with a maximum of $1,000.00 on dental expenses.”
· Arizona Pioneers’ Home documents to be filled out and signed by the applicant at the time of the application:
o Defining Independence
o Affidavit of Mining Employment (Miners only)
o Admission Form
o Resident Statement (Pioneers only)
o U.S. Citizenship Verification
o Notice to Applicant of Intent to Obtain A Consumer Report
o Disclosure Regarding Background Investigation
o Acknowledgment and Authorization for Background Check
o Resident Representative Contact Info
o Primary Care Physician
o Health Insurance Information
o Authorization for Disclosure of Health Information (Arizona Pioneers’ Home staff will request two (2) years of medical records from all providers)
o Medical Provider List
o Mortuary Selection
o Rules
o Acknowledgements
- Insurance Requirements
o A resident must maintain either VA coverage, OR an Advantage plan that includes Medicare Part D (Drug plan), 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. All insurance coverage must be valid in Yavapai County.
o 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.
- You will need to supply copies of:
o The following cards, front and back
ü Social Security Card
ü Arizona Driver's License/Arizona Photo ID
ü Medicare card
ü Veteran’s ID (if applicable)
ü Medicare card (if applicable)
ü Supplement insurance card (if applicable)
ü Medicare Part “D” insurance card (if applicable)
ü Advantage Plan insurance card (if applicable)
ü AHCCCS card (if applicable)
o Healthcare and Financial Directives – We have forms for each at the end of the application that you may use if you don’t already have these documents filled out and signed by your designated Resident Representative(s).
ü Healthcare Power of Attorney
ü Mental Health Power of Attorney
ü Financial Power of Attorney
ü Living Will
ü DNR or FULL Code (You must choose one OR the other, do not fill out both.)
- Payment for Care Packet (Pioneers & Financially Disadvantaged Miners only)– Informational packet that includes the list of financial statements/documents we need.
o Residential Financial Disclosure form
o Bank statements: The most recent three months of bank statements for ALL active checking, savings and money market accounts.
o Social Security: Please turn in the Benefit Amount Letter that the Social Security Administration sends out in December, if you have it.
o Tax Return for the previous tax year – Federal and State
o Pension
o CD’s/interest bearing accounts
o Annuities and/or Dividends
o Loan payments or receivable payments from others
o House/property value: address of house/property.
o Assets: Have you disposed of any assets with a value greater than $1000, (property or money) in the past 24 months?
o Trust Fund documents
o Accounts or income not listed above
o Part “D”: premium statement
o Health insurance: premium statement
o Burial or life insurance policy: (One of these could be deducted from your rent)
· Per Arizona Pioneers’ Home policy, prior to admission an applicant is required to furnish the Arizona Pioneers’ Home with a credit history report. Debts of this type must be paid out of the monthly spending allowance they are permitted to keep each month.
o There are several ways to obtain a credit report. You only need to do ONE of these.
ü Online at https://www.annualcreditreport.com/requestReport/requestForm.action
ü Call ONE of the three reporting companies. We only need ONE report.
· Equifax 1 (888) 548-7878
· Experian 1 (888) 397-3742
· TransUnion 1 (800) 916-8800
If you have questions or wish to request an Admissions Application, please call Administrative Services at the Arizona Pioneers’ Home 928-277-2721.