321 N. Chestnut, Lindsborg,
Kansas 67456
Phone:
785-227-2334 / Fax: 785-227-3138
Email: info@bethanyhome.com
Website: www.bethanyhome.com
Name_______________________________________________________________________________
Last First Middle Telephone
Address__________________
Town______________________ State________ Zip Code ___________
Living arrangements (circle one): Living Alone
/ Spouse/Partner / Children / With
Others _____________
Date of Birth: Month
________ Day ________ Year ________ Age ________ Sex: F _____ M _____
Place of Birth: _________________________ Former
Occupation: _____________________________
Marital Status (circle one): Single / Married /
Widowed / Divorced / Separated / Other: ______________
Name of Spouse/Partner:
_______________________________________________________________
PERSONS TO BE NOTIFIED (if more space is needed
please attach paper with information):
Name Relationship Address-Zip Code Telephone
1. ________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
Church Affiliation: Baptist / Catholic / Covenant
/ Lutheran / Methodist / Other:______________________
Name of Church:
_____________________________________________________________________
Name of Pastor: ________________________ Address
_______________________________________
Funeral Home: _________________________ Address
_______________________________________
* Please attach
copy of cards. Thank you!
Social Security No.*
_________________________ Veteran
Benefits: ___________________________
Medicare #: * __________________________ Medicare D*(Pharmacy) Ins:
_______________________
Blue Cross-Blue Shield #: *
______________________________________________________________
Life or Health Ins. _____________________________
Nursing Home Ins. ________________________
Title XIX Assistance No.
______________________________________________________________
Wishes to be on Cottage waiting list Yes ___________ No __________
Existing Advance Directives. List names as
applicable:
Health DPOA:
________________________________________________________________________
Financial DPOA:
______________________________________________________________________
Financial Information:
Responsible Party:
___________________________________ Relationship: _____________________
Medical Information:
Dentist: _______________________ Address
_______________________ Tel. (___)_______________
Ophthalmology/Optometrist: ________________
Address ________________ Tel. (___)_____________
Physician: ____________________ Address ________________________
Tel. (___)_______________
Physician’s Comment: General Condition: (Please
include Diagnosis & Mental Status)
Signed
_____________________________________________________________M.D.
All information
contained in the application requires complete answers and remains the
confidential property of Bethany Home. This preliminary information is required
so that accurate evaluations may be made. We reserve the right to make room
adjustments as deemed necessary. Bethany Home residents and families will be
consulted before changes.
If admitted I
agree to cooperate with making life in Bethany Home pleasant and agreeable, and
to comply with the Rules and Regulations of The Home. And, I declare the answers to the foregoing questions to be true,
full, and correct tot he best of my knowledge.
Applicant’s Signature
_____________________________________________ Date ________________
Co-Signer
_________________________________________ Address __________________________
OFFICE
USE ONLY: Application
Date ________________________________ Approval
Date _________________ Application
Fee ___$35.00_________________________ Waiting List: A ______ IA _______ Interview
______________________________________ Admissions
Date _______________ Comments: _________________________________________________________________________________