Apply for Admission to the Residential Facility

How To

  1. Enclose a copy(s) of your DD Form 214 – Certificate of Release or Discharge from Active Duty, which lists your place of entry and place of discharge, date of entry and discharge, record of service, time lost, and character of service. If you served more than one period please submit a copy of each DD214 you have received. A DD214 must be furnished to us even if you have been here in the past. If you do not have a DD Form 214 – follow instructions on the enclosed Standard Form 180 (SF180) and mail it to the designated area listed.
  2. Proof of Connecticut (CT) Residency – General Statutes of Connecticut Revised January 1, 2009, Volume 9, Section 27– Armed Forces and Veterans, General Provisions Section 27-103(b) states “veteran” means any veteran who served in time of war, as defined in subsection (a) of this section, and who is a resident of this state, provided, if he was not a resident or resident alien of this state at the time of enlistment or induction into the armed forces, he shall have resided continuously in this state for at least two years.
  3. Enclose a copy of your Health Insurance Card(s) – VA CT Healthcare System card (Newington or West Haven Campus), Medicare, Medicaid Title XIX card and/or other health insurance cards you have.
  4. Physician to complete the enclosed Medical Certificate on Pg. 11 & 12.
  5. Complete and sign the application along with the following forms:
    • Release of Information Form (State of CT DVA)
    • Request for and Authorization to Release Info (Federal VA Form 10-5345)
    • Billing Information Form
    • Income Assets Questionnaire
    • Application for Health Benefits (VA Form 10-10EZ)
  6. Your application will be delayed until this information is received. Please make an appointment with your Primary Care Provider at VA CT Healthcare System (Newington or West Haven Campus) to obtain the following information:
    • Name of Primary Care Provider at VA CT Healthcare System
    • A current PPD or chest x-ray, and lab report
    • A current psychiatric and substance abuse assessment
    • A current medical assessment and list of medications
    • Application for Health Benefits (10-10EZ) Form
  7. Enclose a copy of the Probate Court document – if a Conservator and/or Power of Attorney has been appointed for you.
  8. Enclose a copy of a Living Will if you have one, enclose a copy of your assigned Health Care Agent and/or a Durable Power of Attorney document(s) if applicable.
  9. Enclose a copy of any Legal Dispositions - Recent court cases or current terms/conditions of Probation/Parole.
  10. Meet criteria for admission outlined under Eligibility.

Omissions, false information, or lack of sufficient detail, will result in the delay or denial of the processing of your application.

Please be advised that a date for admission will not be considered until all documents are submitted and the application is reviewed and approved.