| **Be careful of
the point system as you may accumulate additional fees each
month. |
Does the
extended Care Facility you chose use the "point system" for
billing charges?
Or is it a flat monthly fee? |
____________
|
What is the
base rent for the room desired? |
____________ |
Is there an
initial deposit or assessment fee? If so, how much |
____________
|
Is there a fee
for...
Assistance with personal care (bathing, dressing, etc.) |
____________
|
Laundry service
fee |
____________ |
Housekeeping |
____________ |
Meals |
____________ |
Medication
Management |
____________ |
Telephone
Service |
____________ |
Television |
____________ |
Transportation
Recreation and Outings |
____________ |
Grooming
needs/supplies (pull ups, toothpaste, shampoo, etc.) |
____________ |
Assistance with
ambulation |
____________ |
Misc. |
____________ |
Misc. |
____________ |
Misc. |
____________ |
Hair care
(Beauty shop) |
____________ |
Total
charges for the month |
____________
|
| |
|
