Long Term Care Agencies and Facilities Comparison Worksheet

As you shop for long term care insurance, think about what kind of long term care will be available to you. This will affect the type of long term care insurancecoverage you decide to purchase. To help you decide, the following worksheet may be useful.

You will need to find out what agencies and facilities provide long term care in the area where you would be most likely to need care, the scope and cost of their services, then fill in the blanks.

The worksheet can be adapted and expanded to fit your situation, but it gives you an organized starting point for gathering information that will help you make the right decision. You can record information for two agencies/facilities per worksheet.

HOME HEALTH AGENCY

Name of Home Health Agency #1 _______________________________

Address _______________________________ _______________________________ _______________________________

Contact Person _______________________________

Phone_________________________

E-mail_________________________

Check which types of care are available and list the cost

__ Skilled Nursing Care Cost/Visit $______________

__ Home Health Care Cost/Visit $______________

__ Personal/Custodial Care Cost/Visit $______________

__ Homemaker Services Cost/Visit $______________

NURSING FACILITY _______________________________

Address _______________________________ _______________________________ _______________________________

Contact Person _______________________________

Phone_________________________

E-mail_________________________

__ Skilled Nursing Care Cost/Visit $______________

__ Personal/Custodial Care Cost/Visit $______________

OTHER FACILITY

Other possible facility/service #1 (e.g. assisted living, adult day care)

______________________________

Address _______________________________ _______________________________ _______________________________

Contact Person _______________________________

Phone_________________________

E-mail_________________________

What services are available? _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ _____________________________ Cost $_______________________

Name of Home Health Agency #2 _______________________________

Address _______________________________ _______________________________ _______________________________

Contact Person _______________________________

Phone_________________________

E-mail_________________________

Check which types of care are available and list the cost

__ Skilled Nursing Care Cost/Visit $______________

__ Home Health Care Cost/Visit $______________

__ Personal/Custodial Care Cost/Visit $______________

__ Homemaker Services Cost/Visit $______________

NURSING FACILITY _______________________________

Address _______________________________ _______________________________ _______________________________

Contact Person _______________________________

Phone_________________________

E-mail_________________________

__ Skilled Nursing Care Cost/Visit $______________

__ Personal/Custodial Care Cost/Visit $______________

OTHER FACILITY

Other possible facility/service #1 (e.g. assisted living, adult day care)

______________________________

Address _______________________________ _______________________________ _______________________________

Contact Person _______________________________

Phone_________________________

E-mail_________________________

What services are available? _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ _____________________________ Cost $_______________________