Facility Listing Form - New LifeStyles Online

Please read and complete all sections of this form.

Listings are a paid advertising option. If you have signed up for advertising with New LifeStyles, please complete the following form. If you would like more information on advertising with New LifeStyles, please click here.

ALL of this information will be published as it is listed here. DO NOT submit duplicate information for the same facility. Please complete a separate form for each facility or section you wish to include in New LifeStyles. If you have questions about this form or need additional information, please call us at 800-869-9549.

* Required Items

*Name:

*Contact Name:

*Address:

*City:

*State:

*Zip:

*Phone:

( ) -

*Email:

*Preferred Contact Method:

Display address in listing?

Yes No

Web Address:

Number of Beds/Units:

	Beds
	Units
	Apts
	Other

Private Pay Rates:

Financial Assistance:
(Check all that apply)

Medicaid/Medical
Medicare
NP (Non-participating in Medicare or Medicaid)
VA (Veterans Administration Contract)

*Levels of Care:
(Check all that apply)

AL - Assisted Living
ALZ - Alzheimer's/Dementia Diagnoses
CCRC - Continuing Care RET Community
HC - Home Care Provider
HOS - Hospice Provider
IV - Intravenous Therapy
RES - Residential Care
RET - Retirement Community
RHB - Rehabilitation Therapy
RSP - Respite Care
SNF - Skilled Nursing Facility
SUB - Sub Acute Care
Other

Please use the space below to write a short description of the facility and/or the services you wish to advertise.

Description text must be limited to 375 characters. This character count includes each letter, spaces between words and all punctuation marks. Approximately 5 lines of type can be used.

If the text is too long, it will be edited to fit. The complete listing will be typeset and you will receive a proof for your approval before publication.

characters remaining

Notes/Instructions: