swiss village information packet

PERSONAL INFORMATION

First Name MI Last Name

Mailing Address

City State Zip Phone ( ) ‐

Email Address

Social Security Number Date of Birth Age Birthplace Legal Residence During Past Ten Years

Father’s Name Birthplace Mother’s Name Birthplace

MARITAL INFORMATION Marital Status □Single □Married □Widow □Widower □Divorced □Separated

With Whom Do You Reside

First Marriage to Whom Date of Marriage Date Ended

Second Marriage to Whom Date of Marriage Date Ended

EMPLOYMENT Past Occupation Last Place of Employment / Date Employment Ended

Highest Level of Education Completed Spouse’s Occupation

Have You Ever Been Employed By Swiss Village? If Yes, Please Indicate Position and Years Employed

CHILDREN/BROTHERS AND SISTERS OR CLOSE RELATIVES (IF NO LIVING CHILDREN) Name Address / Phone Marital Status Occupation Relationship

Name Address / Phone Marital Status Occupation Relationship



APPLICATION FOR ADMISSION

CHURCH RELATIONSHIP Church Affiliation Name of Pastor

Church Address Phone ( ) ‐

PHYSICAL CONDITION Condition of Your Health □Good □Fair □Poor

Do you require special attention or care? □Yes □No

Are you able to be up and about, and to take care of your personal needs such as dressing, bathing, toileting, eating independently, etc? □Yes □No I understand, Swiss Village is a Smoke‐Free Campus and smoking is not permitted anywhere on Swiss Village’s property at anytime. Signature:______________________________________ Do you require a special diet? (If so please indicate type of diet)

Are you on any medication? (If so please indicate medication)

Condition of Hearing □Good □Fair □Poor

Condition of Eyesight □Good □Fair □Poor

Have you had any of the following: □Stroke □Epileptic Attack □Heart Attack □Arthritis □Diabetes □Broken Hip or Limb □Mental Illness □Communicable Disease, such as Tuberculosis □Other Chronic Ailments Name of Physician

Address of Physician Phone ( ) ‐

Name of Dentist

Address of Dentist Phone ( ) ‐

Name of Optometrist/Ophthalmologist

Address of Optometrist Phone ( ) ‐

INSURANCE Life Insurance Company: Amount: $ Premium: $ Beneficiary: Insurance Agent: Healthcare/Assisted Living Long Term Care Insurance: Daily Benefit: $ Length of Coverage: Insurance Provider: Intermediate Healthcare Coverage: □Yes □No Medicare Claim Number: (Please submit a copy of your Medicare Card)

Medicare Supplemental Insurance or Medicare Replacement Plan: Identification No.: Effective Date: Policy No. / Group No.: (Please submit a copy of your Medicare Supplement/Replacement Card)

WILL/ LIVING WILL/POWER OF ATTORNEY/HEALTHCARE REP Have you made a Will? □Yes □No If Yes, in whose possession is it now? Do you have a Power of Attorney? □Yes □No Name of Power of Attorney: (Please submit a copy of Power of Attorney Paperwork)

Do you have a Living Will? □Yes □No (Please submit a copy of Living Will Paperwork)

Do you have a Healthcare Representative? □Yes □No Name of Healthcare Representative: (Please submit a copy of Healthcare Representative Paperwork)

Do you have a Guardian? □Yes □No Name of Guardian: (Please submit a copy of Guardian Paperwork)

OTHER INFORMATION Are you a Veteran? □Yes □No If Yes, Have you applied for Veteran Benefits? □Yes □No www.va.gov

Name and Address of Attorney: Phone: ( ) ‐ Have you transferred any property, real estate or personal, within five years prior to application? □Yes □No If Yes, Explain: Is someone willing to supplement your support if you should outlive your assets? If so who? I agree to make application for Public Assistance (Medicaid) when my resources are depleted. Signature:______________________________________________ To whom should the monthly statement be sent? Name: Address: Phone: ( ) Have funeral arrangements been made? □Yes □No If No, who is to make the arrangements? Name of Funeral Director: Address: Phone: ( ) ‐ Name and Location of Cemetery: Cemetery Lot Number: Cemetery Grave Marker:

EMERGENCY CONTACT INFORMATION Name: Address: Phone: ( ) ‐ Cell Phone: ( ) ‐ Relationship: Name: Address: Phone: ( ) ‐ Cell Phone: ( ) ‐ Relationship:

FINANCIAL INFORMTION Checking Account: Savings Account: CD’s, Annuities, Stocks, Bonds, Mutual Funds:

Real Estate (Home Value): Other Real Estate:

Automobile (Auto 1): Automobile (Auto 2):

Other Assets: Total Assets: $

INCOME His Monthly Her Monthly Joint Annually Social Security: Pension: Investments: Annuity: Other: Total Income $ $ $

EXPENSES Medication: Medical Supplement: Insurance Premiums: Transportation: Contributions: Telephone: Travel: Personal: Other Expenses:

Total Expenses: $ LIABILITIES Mortgage: Credit Cards: Notes: Other Liabilities:

Total Liabilities: $

PREFERENCE OF ACCOMODATIONS Type and location of Room Preferred: Desired Date of Entrance:

Additional Remarks:

PAYMENT WITH APPLICATION – RESIDENTIAL AND INDEPENDENT LIVING (PAYMENT NOT APPLICABLE IF ENTERING HEALTH CARE DIRECTLY) Amount paid with application is $______________ which is a non‐refundable application processing fee. This does not apply toward the initial charge (facility fee) and is not deductible for tax purposes. I understand and agree that the acceptance of the amount paid with this application does not constitute acceptance or approval of the application, and the applicant must meet all other requirements for entrance into Swiss Village. The applicant agrees, at his/her expense, to submit to a physical examination before entering. This form will be supplied near the time of entrance. To the best of my knowledge, the foregoing answers are true and represent the facts fairly. I understand that this information is to be held confidential and to be used for the purpose of determining my eligibility for residence at Swiss Village. I agree not to impair my ability to meet financial obligations by transferring assets without consent of the Village, other than to meet ordinary and customary living expenses. Signature of Applicant: _________________________________________________ Date: / / Form filled out by (if other than applicant): _________________________________ Date: / / OFFICE USE ONLY

Date Application Received: / / Date of Payment of Application Processing Fee: / / Copy of Check Made: □Yes □No Signed Disclosure Statement: □Yes □No Admitted: / / Room Number: Locker Number:

***All persons who wish to enter Swiss Village are asked to furnish the information on this form. The information submitted, to be treated confidentially, is needed so that proper selection and evaluation may be made. When two persons are making application together, a separate application form should be filled out by each. Applicants may find the help of a friend or member of the family desirable in filling out this form.

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Duplex Homes

Clo.

Bed room13 ’-11 ”x 1 1’-9 ”

Living/Dining18’ x 21’-4” TV

TV

Den18’ x10’

A/C

Laundry12’ x 6’

2 Ca r Ga rage21’ x 22 ’

Kitche n16’ x 12 ’

Fo yer4’ x 8’

Ma ster B ed roo m14 ’ 6” x 1 4’

B ath

Bath

Clo.

Clo.

Clo.

Patio

12 ’ x 8’

Clo.

Ma ster Suite

13’ -4”x 12’-6”

B edroom

11’ 8” x 10’ 2 ”

M. Bath

Bath

Cl o.

Clo.

Clo .

TV Living

13 ’-6” x 21 ’

w/ C athedral

Ce iling

Dining

11’ x 10’

Den

11 ’ x 11 ’

Kitche n

12 ’ x 10’ 7”

Ga rage

21 ’x 2 1’

Clo.

Matterhorn

Bernerhof Deluxe

• Attached Garage• Dishwasher, Refrigerator, Stove Included• Den• Full Size Kitchen• Living/ Dining Room• Patio • Two Bedrooms / Bathrooms

“I don’t have to worry about anything. I only own the space inside the walls, if something goes wrong, Swiss Village takes care of it.” -Swiss Village North Campus Resident

“We lived in a Tri-Level before moving to our duplex, and we actually gained space, and we

are on one level.”-Swiss Village

North Campus Resident

Bernerhof: Living Space 1,359 sq. ft. Payment Plan Facility

FeeFund

DepositTotal Facility Fee

AmortizationFund Deposit Amortization

Daily Rate*

Traditional Plan

$65,906 $21,969 $87,875 First Year: $49,430Second Year: $32,953Third Year: $16,477Fourth Year: $0

During Years 5-10 of residency at a rate of approx. $305 per month

$20.40

58.3% Refund Plan


Fully Refundable $76,847

$20.40

Facility Fee/ Monthly Plan

$65,906 $300 Monthly Facility

Fee

$65,906 First Year: $49,430Second Year: $32,953Third Year: $16,477Fourth Year: $0

Additional Monthly Facility Fee of $300

Not Refundable

$20.40

Bernerhof Deluxe: Living Space 1,435 sq. ft. Payment Plan Facility

FeeFund



Daily Rate*

Traditional Plan



$21.40

58.3% Refund Plan



$21.40



Fee



Not Refundable

$21.40

Matterhorn: Living Space 1,444 sq. ft. Payment Plan Facility

FeeFund



Daily Rate*

Traditional Plan



$21.40

58.3% Refund Plan



$21.40



Fee



Not Refundable

$21.40

Daily Rate* covers building insurance, lawn care, snow removal, trash pickup, water, sewer, cable television, and maintenance/ repairs to building and appliances. Effective 6/1/2013

Independent LIvIng

One Bedroom

• Attached Garage• Dishwasher, Refrigerator, Stove Included• Full Size Kitchen• Living/ Dining Room• Patio

“Swiss Village is one of the finest retirement homes available.” -Swiss Village Resident

“It is convenient to have a library, boutique, banking

center, and hair salon all in one place.”

-Swiss Village Resident

Living/

Dining

Patio

Bedroo m

Kitchen

Bedroom

Closet

Storag e

Living/Dining

Patio

Bedroo m

Kitchen

Storage

Two Bedroom

Independent Living Apartments: Basel & Zermatt HausApartment Facility

FeeFund



Daily Rate*

Traditional PlanOne Bedroom Apartment(724 Sq. Ft.)



$20.10

Monthly PlanOne Bedroom Apartment(724 Sq. Ft.)

$8,606 Included in Daily Facility

Fee

$8,606Plus Additional Daily Facility

Fee

Additional Daily Facility Fee scheduled to end after 84 months

N/A

$37.10

Traditional PlanTwo Bedroom Apartment (1007 Sq. Ft.)



$20.60

Monthly PlanTwo Bedroom Apartment (1007 Sq. Ft.)


Fee


Fee


N/A

$44.55

Daily Rate*: The daily rate covers building insurance, lawn care, snow removal, trash pickup, water, sewer, laundry facilities, cable television, housekeeping of common areas, and maintenance/repairs to building and appliances. (The monthly plan daily rate includes an additional fee for facility fee and fund deposit.) Attached garages are available for an additional $50.00 per month.

Traditional Plan Facility Fee and Fund Deposit: The facility fee is amortized over a four year period and is only refundable if the resident leaves Swiss Village or passes away. The entire fund deposit is refundable through the fourth year of residency. During the fifth through tenth year of residency, the fee is amortized according to the above schedule.

Monthly Plan: Non-refundable.

Independent Living Apartments: Zurich & Lucerne HausApartment Facility

FeeFund



Daily Rate*

Traditional PlanOne Bedroom Apartment(636 Sq. Ft.)



$19.90

Monthly PlanOne Bedroom Apartment(636 Sq. Ft.)


Fee


Fee


N/A

$35.75

Traditional PlanTwo Bedroom Apartment (917 Sq. Ft.)



$20.40

Monthly PlanTwo Bedroom Apartment (917 Sq. Ft.)

$11,475 w/ Additional

Daily FeeIncluded in

Daily Facility Fee

$11,475 Plus Additional Daily Facility

Fee


N/A

$43.05

Effective 6/1/2013

Residential living

Kitchen/Dining

Living

Bedroom

Bedroom Alcove

Living

StorageBath

Alcove Unit

One Bedroom Unit

“There are so many activities available. We can be as active as we desire.”

- Swiss Village Resident

• Emergency Call System • Three Meals Daily in Main Dining Room

• Weekly Housekeeping Services

Residential Living

Apartment Square Feet

(approx.)

Facility Fee Facility Fee Amortization

Daily Rate*

Double Occupancy

Rate*Studio Apartment Langfeld & Steingarten

250-330 $15,300 First Year: $11,485Second Year: $7,650Third Year: $3,825Fourth Year: $0

$49.15 N/A

Alcove Apartment Steingarten

410 $22,700 First Year: $17,025Second Year: $11,350Third Year: $5,675Fourth Year: $0

$50.60 N/A

Alcove ApartmentLangfeld


$51.90 N/A

Studio Apartment Langfeld


$75.90 N/A

One Bedroom Apartment Langfeld & Steingarten


$75.90 $101.20

One Bedroom Apartment Langfeld


$77.90 $105.20

Daily Rate*The daily rate includes cable television, laundry facilities, maintenance/repairs, three meals daily, utilities, and weekly housekeeping.

Healthcare DiscountResidents who have paid a facility fee of $15,300 or more are eligible for a discount of $8.75 per day in healthcare once apartment has been vacated.

Effective 6/1/2013

Assisted Living

588 Sq. Ft.

750 Sq. Ft.

• Bathing Assistance

• Medication Management

• Personal Laundry Services

• Scheduled Activities

• Three Meals Daily

• Weekly Housekeeping

“I love all of the activities at Swiss Village. There is always something to do.”

- Swiss Village Resident.

Assisted Living: Blumengarten

Apartment/ Square Feet (approx.)

Facility Fee

Facility Fee Amortization

Daily Rate Single

Occupancy*

Double Occupancy

Rate*

One Bedroom Apartment (475 Sq. Ft.)

$27,330 First Year: $20,497.50Second Year: $13,665.00Third Year: $6,832.50Fourth Year: $0

$93.50 N/A



$98.50 $157.60



$103.50 $165.60

Daily Rate*The daily rate includes assistance with bathing, cable television, laundry services, maintenance/repairs, medication management, three meals daily in Blumengarten dining room, utilities, and weekly housekeeping.

Healthcare DiscountResidents who have paid a facility fee of $15,300 or more are eligible for a discount of $8.75 per day in healthcare once apartment has been vacated.

Effective 6/1/2013

Rehab / healthcaRe

Edelweiss Place

Lavendel PlaceSonnenblum Place

Alpenrose Place

HealtHcare• Daily Activities• Dementia Care Unit• Medicare & Medicaid Certified• Private Rooms• Semi Private Rooms• Skilled & Intermediate Care• Therapy Services

SHort term reHabilitation• Private Furnished Suites• Private Bath w/ Walk-in Shower• Flat Screen TV and Cable• Wireless Internet and Phone• Private Entrance and Parking• Therapy Services

Private Rehab Suites

HealthcareRoom Square

FeetDaily Rate

Intermediate CareDaily Rate

Skilled Care

Semi-Private Room Sonnenblum 218-276 $175.60 $196.70

Private Room Sonnenblum 205 $190.55 $211.65

Semi-Private Room Lavendel 316 $182.60 $203.70

Private Room Lavendel 197 $196.75 $217.85

Semi-Private Room Alpenrose (Dementia Care) 319 $192.10 $213.20

Private Room Alpenrose (Dementia Care) 197 $206.25 $227.35

Private Room Shared Bathroom Edelweiss 240 $197.75 $218.85

Private Room Shared Bathroom Edelweiss 270 $200.35 $221.45

Private Room Private Bathroom Edelweiss 250 $203.60 $224.70




Short Term RehabilitationRoom Square

FeetDaily Rate

Intermediate CareDaily Rate

Skilled Care

Private Furnished Suite 250 $265.50 $265.50

Effective 6/1/2013

Swiss VillageCelebrate Retirement... Engage Life!

Berne, Indiana

260.589.3173 www.swissvillage.org

Retirement Living At Swiss Village

Situated on 185 acres of beautifully landscaped and gently rolling land, Swiss Village residents are free to experience a peaceful, rural setting, surrounded by five ponds and walking paths. Picturesque views can be found at Swiss Village each season of the year.

Swiss Village offers small town living with all of the comforts of home. As the area’s premier continuing care retirement community, residents may choose from a variety of living options to meet their ongoing needs.

• Duplex Homes • Independent Living Apartments • Residential Apartments • Assisted Living Apartments • Healthcare & Dementia Care • Therapy Services

Celebrate retirement... engage life!

Community Life

An on-site banking center, boutique, hair salon, computer lab with internet, library, woodworking shop, a variety of craft classes, and intergenerational programming all can be enjoyed by Residents of Swiss Village. Residents may engage in regularly scheduled activities and trips, or may sit back and savor the contentment of Swiss Village’s community life.

In addition, Residents may take advantage of The Arthur & Gloria Muselman Wellness Pavilion, which provides a resort style of living with its aquatic center, cardio and strength training equipment, fitness classes, jacuzzi, and massage therapy. Residents may also enjoy wireless internet while lounging by the fire with a cup of coffee.


Independent LIvIng

Swiss Village’s North Campus is a neighborhood of 28 duplex homes located near the Arthur & Gloria Muselman Wellness Pavilion. Swiss Village’s main campus is the home of 52 independent congregate living apartments with attached garages. Residents residing in a duplex or independent living apartment receive peace of mind by freeing themselves from the responsibilities of yard work and home maintenance. Each duplex and apartment is equipped with an emergency call system. In the event that healthcare services are needed, residents are given precedence over individuals living outside of the Swiss Village Community.


“Swiss Village is one of the finest retirement homes available.”

-Swiss Village Resident

ResIdentIaL and assIsted LIvIng

A variety of residential and assisted living apartments are available on Swiss Village’s main campus. Residents living in residential apartments receive weekly housekeeping services and three meals a day in the main dining room. Assisted living apartments are available for residents who may need additional assistance with certain activities of daily living.

Apartments range in size from one bedroom units to studio units. Each apartment is equipped with an emergency call system. In the event that healthcare services are needed, residents are given precedence over individuals living outside of the Swiss Village Community.


Healthcare and Dementia Care

Swiss Village offers 128 skilled and intermediate care healthcare beds, and is certified to provide Medicare and Medicaid services. Semi-private and private rooms available. Alpenrose Place is a unique healthcare setting within Swiss Village that is dedicated to making a constructive difference in the lives of those who have memory loss. It is specifically designed and staffed for residents who have functional limitations resulting from Alzheimer’s Disease or other disorders that impair memory. Alpenrose Place is a secured environment that is well supervised with a high staff to resident ratio. Swiss Village staff is committed to the preservation of the personal dignity of each resident and to providing life engaging opportunities for them for as long as possible.


Healthcare Services

Our competitive daily rates include three meals a day, utilities, laundry services, and required nursing care, with qualified nurses on duty 24-hours a day. All rooms have telephone and television hook-ups, with some rooms equipped for computer internet access. A variety of daily activities are available based on the individual’s needs, ability levels, and interests. Community lounges are open to family members and guests.

Therapy Services

Individualized therapy services are available for residents living at Swiss Village. Therapists and care teams create therapy programs specific to individual recovery goals. Services include physical, occupational, and speech therapy.


swIss vILLage MIssIon stateMent

Swiss Village Retirement Community is a not-for-profit corporation committed to providing quality services and affordable facilities in a Christian environment that

enhances life with dignity, meaning, and opportunities for growth.

Swiss Village does not discriminate on the basis of race, color, religion, national

origin, sex, or handicaps.

Swiss Village1350 W. Main StreetBerne, Indiana 46711

260.589.3173 • www.swissvillage.org

Medicare Coverage in Short - term Rehab i l i tat ion

1350 W. Main Street • Berne, IN 46711 • www.swissvillage.org

Rehab i l i tat ion Ser v ices Rehab i l i tat ion Programs

Celebrate Retirement... Engage Life!

Excellence in RehabilitationHealth & Rehabilitation at

Therapy Gets You Back to

Safe Transitioning

Evidence-based Treatment

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www.swissvillage.org

Arthur & Gloria Muselman

Wellness Pavilion

Swiss Village, Inc. Berne, Indiana

Free Fitness Classes

• Balance • High / Low Impact Cardio

• Relaxation / Stretching • Toning / Conditioning

• Water Aerobics / Water Walking

• Water Arthritis

Hours oF operation

Monday - Thursday 5:00 a.m. - 9:00 p.m. Friday 5:00 a.m. - 6:00 p.m. Saturday 7:00 a.m. - 4:00 p.m. Sunday 1:00 p.m. - 5:00 p.m.

“Swiss Village’s Community Wellness Center exists to improve the quality of life experience for all members by providing the facilities, equipment, programs, and staff to nurture wellness.”

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MeMbersHip opportunities

Monthly Membership (with yearly contract agreement, no sign-up fee)

Adult Membership $45.00 Family Membership (Household) $65.00

Monthly Membership (without yearly contract agreement, no sign-up fee)

Adult Membership $50.00 Family Membership (Household) $80.00

Daily Rates

Individual Non-Members $7.50

Family Non-Members (Household) $10.00

Membership Discounts

Swiss Village Residents Free

Swiss Village Employees 50% off

One Personal Training Session Free

Fitness Classes Free

SilverSneakers® Fitness Program

For Registration Information Visit www.swissvillage.org

*** Monthly memberships paid via EFT are withdrawn on the first business day of the month. Monthly membership paid by check or cash require an additional $5.00 processing fee.

“Exercise is like a savings account. The more you put in, the more you

are going to get out of it.” -Ron Ekovich

aMenities

• Aquatic Facility w/ Jacuzzi

• Billiards • Cardio Fitness, Precor Tredmills, Ellipticals, AMTs, Recumbent Bikes, Nu-Steps • Coffee Bar • Fitness Classes

• Locker Rooms w/ Showers • Multi-Use Room w/ Kitchen (additional charge)

• Nintendo Wii

• Strength Training, Paramount Strength Machines & Tag Free Weights

serviCes

• Child Watch

• Body Assessments

• Health Education

• Massage Therapy / Treatments

• Personal Training Sessions

• Swim Lessons, American Red Cross Certified

• Weekly Blood Pressure Checks • Weight Loss Programs

swiss village information packet

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