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July 30, 2010

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Elite Provider Network

Corporate/Community Education

Elite
Provider

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Over 60% of people providing care for their parents are working full or part-time. More than 40% are also caring for children under the age of 18.

* required field

Elite Long-Term Community Provider Network Sign-Up:

* Name:

* Owned By:

* Address:

* City:

* State:

* Zip Code:

* Main Contact:

* Phone #:

* Email:

Web Address:

Company Brochure:
(pdf's and word docs only)

Non-Profit Org.?:

Non-Profit For Profit

* Care Levels: please check all that apply

Independent Living
Assisted Living
Assisted Living Memory Care
Nurse Care
Nurse Memory Care
Continuing Care Retirement Community (CCRC)

Additional Care Services:

Rehabilitation
Physical Therapy
Speech Therapy
Occupational Therapy
Respiratory Therapy
Respite Care

Costs:

Payment methods: Private Pay Medicare Medicaid

* Entrance Fee: Yes No

* Amount Range:

* Low End $

* High End $

Comments:

Independent Living:

Studio Range:

Low End $

High End $

* 1 Bedroom Range:

* Low End $

* High End $

* /

2 Bedroom Range:

Low End $

High End $

Add. Occupant Range:

Low End $

High End $

Comments (unit types):

Services Included: please check all that apply

Utilities Phone Meals per day Linen Service	Cable Emergency Call System Housekeeping: per week Security
Assistance with: Bathing Dressing Grooming Additional Services available at $ per service

Comments (list additional services available and their costs if applicable):

Assisted Living:

Studio Range:

Low End $

High End $

* 1 Bedroom Range:

* Low End $

* High End $

* /

2 Bedroom Range:

Low End $

High End $

Add. Occupant Range:

Low End $

High End $

Comments (unit types):

Services Included: please check all that apply

Utilities Phone Meals per day Linen Service	Cable Emergency Call System Housekeeping: per week Security
Assistance with: Bathing Dressing Grooming

Comments (list additional services available and their costs if applicable):

Assisted Living (Memory Support):

Studio Range:

Low End $

High End $

* 1 Bedroom Range:

* Low End $

* High End $

* /

Comments (unit types):

Services Included: please check all that apply

Utilities Phone Meals per day Linen Service	Cable Emergency Call System Housekeeping: per week Security
Assistance with: Bathing Dressing Grooming

Comments (list additional services available and their costs if applicable):

Nursing Care:

* Semi-Private Range:

* Low End $

* High End $

* /

Private Range:

Low End $

High End $

Comments (unit types):

Services Included: please check all that apply

Utilities Phone Meals per day Linen Service	Cable Emergency Call System Housekeeping: per week Security
Assistance with: Bathing Dressing Grooming

Comments (list additional services available and their costs if applicable):

Nursing Care
(Memory Supported):

* Semi-Private Range:

* Low End $

* High End $

* /

Private Range:

Low End $

High End $

Comments (unit types):

Services Included: please check all that apply

Utilities Phone Meals per day Linen Service	Cable Emergency Call System Housekeeping: per week Security
Assistance with: Bathing Dressing Grooming

Comments (list additional services available and their costs if applicable):

Amenities:

Beauty/Barber Shop
Lounge
Fireplaces
Guest Suites
Pool
Golf
Tennis
Valet

Pets
Transportation Services
Library
Computer Access
Chapel
Wellness Center
Concierge Service

Community Comments:

Activities and Programs:

Cards/Games (i.e. Bridge & Bingo)
Music
Fitness
Water Activities
Crafts

Reading
Computers
Movies
Religious/Spiritual Activities
Occasional Excursions

Comments:

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