Form H31-7797 "Long Term Care Optional Designation for Determining Resident Charges" - Saskatchewan, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form H31-7797 "Long Term Care Optional Designation for Determining Resident Charges" - Saskatchewan, Canada

Download PDF

Fill PDF online

Rate (4.3 / 5) 7 votes
Drug Plan & Extended Benefits
3475 Albert Street
Regina SK S4S 6X6
Phone 306-787-5023
or Toll-Free 1-800-667-4884
Fax 306-787-8679
LONG TERM CARE
OPTIONAL DESIGNATION FOR DETERMINING RESIDENT CHARGE
I,
(name)
residing in
(facility)
hereby wish to be designated as indicated below for purposes of calculating the income-tested
resident charge. I understand that either designation does not automatically designate me in
this way with other social safety net programs in the federal government (e.g. Guaranteed
Income Supplement) and provincial government (e.g. Saskatchewan Assistance Plan and
other Ministry of Health Programs).
Please check the designation applicable to your situation (check only one box). With this
designation only the resident's income is considered in determining the resident charge.
My spouse and I live in separate dwellings for reasons beyond our control.
However, our marital status has not changed.*
I am separated from my spouse pursuant to a separation agreement or a
judicial separation.** Effective Date
Signed this
day of
, 20
.
Resident's Signature or Spouse's/Supporter's Signature
Name of individual signing above (Please Print)
* Commonly called "involuntary separation"
** Sometimes called "legal separation"
H31-7797
2000/10
Drug Plan & Extended Benefits
3475 Albert Street
Regina SK S4S 6X6
Phone 306-787-5023
or Toll-Free 1-800-667-4884
Fax 306-787-8679
LONG TERM CARE
OPTIONAL DESIGNATION FOR DETERMINING RESIDENT CHARGE
I,
(name)
residing in
(facility)
hereby wish to be designated as indicated below for purposes of calculating the income-tested
resident charge. I understand that either designation does not automatically designate me in
this way with other social safety net programs in the federal government (e.g. Guaranteed
Income Supplement) and provincial government (e.g. Saskatchewan Assistance Plan and
other Ministry of Health Programs).
Please check the designation applicable to your situation (check only one box). With this
designation only the resident's income is considered in determining the resident charge.
My spouse and I live in separate dwellings for reasons beyond our control.
However, our marital status has not changed.*
I am separated from my spouse pursuant to a separation agreement or a
judicial separation.** Effective Date
Signed this
day of
, 20
.
Resident's Signature or Spouse's/Supporter's Signature
Name of individual signing above (Please Print)
* Commonly called "involuntary separation"
** Sometimes called "legal separation"
H31-7797
2000/10