Consumer Checklist
Resident Information
How many units in the ALR?______________________________
Is there a Special Care Residence(SCR)?
Yes_________ No__________ # Units_____________
What type of special needs does the Special are Residence address?
_______________________________________________________
Is there a subsidy program available in the Residence for people with limited incomes and assets? ________________________________
_______________________________________________________
Services Included in the Monthly Fee
Assistance with:
| Daily | Weekly | Time Limit | |
| Bathing | |||
| Dressing | |||
| Grooming | |||
| Transferring | |||
| Toileting | |||
| Meals (#day) | |||
| Housekeeping | |||
| Shopping | |||
| Laundry | |||
| Transportation | |||
| Snacks | |||
| Activities |
OTHER Serrvices Included:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Self-Administered Medicine Management (SAMM)
Included in the monthly fee? Yes____ No ____
If no, what is the cost per month: $_______________
Limited Medication Administration (LMA)
Does the Residence provide LMA? Yes_____ No ____
Included in the monthly fee? Yes____ No ____
If no, what is the cost per month: $_______________
SCR- Monthly Fee: $___________________
Other Questions to Consider
What other services do you need that are not included in the basic service package?
_____________________________________________________________
_____________________________________________________________
What are the associated costs for those services you are seeking that are not included in the basic service package
$______________________________________________________________
Does your Residence offer the opportunity for a respite swtay? If so what is the cost per day? $___________ per day
Is the Residence conveniently located to:
family members_____________________________________________
friends____________________________________________________
doctor_____________________________________________________
hospital____________________________________________________
shopping___________________________________________________
place of worship______________________________________________
other:______________________________________________________
Notes______________________________________________________
___________________________________________________________
___________________________________________________________
Final Checklist
Before you sign an agreement, review the list below to make certain that all of your needs will be met for a cost you can afford:
Know what all of the upfront costs are:
Entrance Fee: $________________
Application Fee: $_________________
Deposit: $_________________
Know what the basic service package includes as well as the cost for that package:
$____________________/month
Know the cost of additional services:Service___________________________ $________________
Service___________________________ $________________
Service___________________________ $________________
Understand exactly what services you are going to receive each day.
Know the circunstances of how often fees will increase and how much advance notice is given to the resident.
Receive a complete copy of the Residency Agreement and the Disclosure Statement.
Take one final tour of the Residence and surrounding community.
Have the name and number of your contact and Residence for follow-up questions.
Notes:
__________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
For more imformation you may call:
Massachusetts Executive Office of Elder Affairs1-800-243-4636
TTY: 1-800-872-0166
Website: http://www.800ageinfo.com/
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