Resident Application

Application/Admit Record
Buhler Sunshine Home, Inc dba Sunshine Meadows Retirement Community

400 South Buhler Rd, Buhler, KS 67522 620-543-2251 FAX 620-543-2328

Room # Admission #
Last Name First Name Middle Move In Date time day
New Address City State Zip Sex Civil Status
S   M   W   D   Sep
County
Previous Address Previous City Prev. State Prev. Zip Phone #;
Age Birth Date Birthplace Social Security #; VA Number
Admit From How Transfer Former Occupation
Church/Synagogue Phone Address Clergyman
DPO/RESPONSIBLE PARTY Relationship Street Address Email (if available) Phone
1.
2.
3.
4.
Billing To... Relationship Street Address Email Phone

Mail Handling Instructions

Permission to use your photo in publications
Yes     No
Business Mail: Resident is to Receive Forward to Responsible Party
Personal Mail: Resident is able to open and read on own: Yes     No
Junk Mail: Discard obvious junk mail?   Yes     No
Hospital Preference Ambulance Preference Funeral Home Preference
Pharmacy Preference Phone Pay Source Care Level
Attending Physician Address Phone
Prescription Drug Plan #/ Group / Bin PCN
Medicare number Other Medical Insurance Policy Number Medicaid Number
Payment Source: *SSI     Private Pay     Medicare     Medicaid     L.T.C. Ins.     HCBS
*Supplemental Security Income (not Social Security)
"This is an equal opportunity facility. Pursuant to the applicant non-discrimination laws of the United States and other governmental bodies, it is the policy of the Buhler Sunshine Home not to discriminate unlawfully against any applicant based on color, religion, national origin, age, sex, race, or disability." Our services and activities are targeted for persons 62 or over. "
How did you hear about our Home? Referred by :
Room #
 
 
Accommodations Daily Rate Monthly Payment Extra nursing care &/or supplies
The resident or responsible party agrees to pay the monthly room charge in advance by the 10th of each month. Additional charges will be billed following the month they are incurred. The health care and services rendered will be as listed in the admission packet.
Resident Signature Responsible Party Signature Date