Map to Pleasant View Home MAKE AN INQUIRY Please call or send us a message through the form below. We’re here to help! 620-585-6411 Δ Application & Financial Information FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Resident Name *FirstLastDate of Birth *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName of person to be contacted: *FirstLastPhone number & email address of person to be contacted: *Marital StatusSingleMarriedWidow/WidowerDivorcedBased on the information you provided and is available from other sources at this time, your pay source will be: *Private PayMedicaid (KanCare)MedicareVeterans AffairsSpouse was a VeteranMedicare Advantage PlanMedicare SupplementPrescriptionsPlease indicate all that could or will apply.Approximate value of assets owned (not including residence and/or vehicle): *$0 to $50,000$50,000 to $100,000$100,000 or moreDoes the resident own a house? *YesNoDoes the resident have long-term care insurance? *YesNoWho will receive monthly invoice?Name of Physician *Emergency Contact #1POA of HealthcarePOA of FinancialGuardianName of Emergency Contact *FirstLast of receive the Address of Emergency ContactAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHave you or are you currently using:AlcoholDrugsSmokingCondition of EyesightGoodFairPoorGlassesAssistance with the following: *ToiletingDressingBathingEatingMedicationList AllergiesAre you suffering from any incapacitation, chronic illness or serious injury? If Yes, please describe.Comments:Application StatusCare is needed at this time.Please call when Pleasant View has an opening.I will call Pleasant View Home when care is needed.Person who filled out the application:Submit
