Application for Residency

Application for Residency 


FOR BEST RESULTS IN APPLYING ONLINE...     USE THE GOOGLE CHROME OR FIREFOX BROWSER.



If you prefer to print this application, click on the link below, fill it out and turn it into our facility in person, or you may mail it to:


  • High Plains Retirement Village
    607 Court Place
    Lakin, KS 67860

Click here to print application

This application will become a part of the "Resident Agreement" and MUST be completed in it's entirety. Kearny County Hospital d/b/a High Plains Retirement Village (HPRV)/Assisted Living, affords equal treatment and access to its facilityies and services for all persons without unlawful discrimination due to race, color, religion, sex, age, national origin, ancestry, or disability. All information will be held in confidence. 

If you would like a copy of this application for your records please enter your email address below.

E-mail:

Resident/Patient

Name:
Address:
Phone:
-
Past/Present Occupation:
Date of Birth:
 / 
 / 
Birthplace:
Marital Status:
Spouse's Name:
If Widowed, name of deceased spouse:
Type of Accommodation Desired:*

Responsible Party

Do you have a Durable Power of Attorney for Medical Decisions?
Do you have Durable Power of Attorney for Financial Decisions?
If someone other than you administers your finances and/or obligations, please list that person's name, address, and telephone number. If Power of Attorney, Trust Officer, or Guardian for financial or medical decisions, please attach copy of legal documents. 

Party Responsible for Financial Matters:

Name (1):
Address (1):
Work Phone:
-
Home Phone:
-

Party Responsible for Medical Matters:

Name (2):
Address (2):
Work Phone (2):
-
Home Phone (2):
-

Where to send current Hospital, Nursing Home, and HPRV/Assisted Living Statements:

Name (3):
Address (3):
Phone (3):
-

Insurance Information

Social Security Number:
Medicaid Number:
Medicare A Number:
Medicare B Number:
Premium Amount $:
Veteran:
Spouse:
Policy Number:
Other Insurance (please Include Names and Policy Numbers):

Long Term Care Insurance

Name (4):
Policy No:

Financial Data

This information is strictly confidential 

Assets:

Bank and Savings & Loan Deposits

Checking Amount:
Saving Accounts & CD's Amounts:

Individual Stocks & Bonds (attach list)

Approximate Current Value:

Mutual Funds/Stocks/Bands/Money Markets

Amount:

Real Estate

Real Estate:
Real Estate Value:

Funds Held in Trust

Trust Value(s):

Other Assets 

Value:
Please Describe Other Assets:
Total Assets:

Liabilites

Home Mortgage (remaining balance):
Loan Payments (remaining Balance):
Other Liabilities:
Please describe other liabilities below:
Total Liabilites:
Net Asset Balance:

Monthly Income

Social Security:
Private/Government Pension:
Investment Income:
Trust Income:
Other:
Please describe other Income below:
Total Monthly Income

Please mark any assets which are jointly held with another individual by putting an asterisk (*) by the asset. Joint tenant(s) of assets must complete the following:

Consent of Joint Tenant

In consideration of the admission of the "Applicant" as a resident of Kearny County Hospital d/b/a High Plains Retirement Village(HPRV), the undersigned hereby unconditionally consents and agrees with HPRV it's successors and assigns, that all joint property listed in resident's application for residency with HPRV on which the undersigned is a joint tenant with resident will be kept available and may be used to pay any sums that become due and payable in accordance with provisions of resident's resident agreement. The undersigned further agrees that he/she will not transfer said assets, or cause said assets to be transferred out of the joint names of resident and the undersigned for any purpose other than to pay for resident's care and services at HPRV and other personal needs of the resident. This consent is given by the undersigned to induce HPRV to admit applicant therein as a resident of HPRV, and shall be applicable as long as applicant is a resident of HPRV in any level of care, other than as a Medicaid recipient.

Digital Signature of Joint Tenant (1):
Date (1):
Digital Signature of Joint Tenant (2):
Date (2):

I make this application for residence in Kearny County Hospital d/b/a High Plains Retirement Village (HPRV) of my own free will and accord. I declare the answers to the foregoing questions to be true, full and complete to the best of my knowledge. Any material misstatement in the information or subsequent transfer of assets empowers HPRV to void the application approval and/or resident agreement. I understand that HPRV may verify statements given in this application. 

Additional Information for application processing
Digital Signature:
500 E Thorpe St, Lakin, KS 67860, 620-355-7111