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6700 E 45th St N Bel Aire, KS 67226

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St. Veronica Senior Behavioral Health Hospital
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About
St. Veronica Senior Behavioral Health Hospital
Events
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- Classes/Activities
Updates

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6550 E 45th St N, Bel Aire, KS 67226

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Residency Application

Step 1 of 6

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Application For Residency

Catholic Care Center, Inc is committed to proving you with quality care and service. In order to accomplish this goal, we need your help in providing the following information. This application will become a part of the "Resident Agreement" and MUST be completed in its entirety. Catholic Care Center, Inc., affords equal treatment and access to its facilities 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.

First Name:(Required)

First

Last Name:(Required)

First

Date:

MM slash DD slash YYYY

Email

Last Permanent Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone:(Required)

Cell:

Past/ Present Occupation:

Date Of Birth:

Month

Day

Year

Birth Place:

Martial Status:

Spouse's Name:

Name of deceased spouse:

Religion:

Church Affiliation:

Pastor:

Referral Source:

Types of Accommodation Desired:

Children

Children List

Name

Address

Telephone Number

Other Close Relatives or Friends

Children List

Name / Relationship

Address

Telephone Number

Responsible Party

Do you have a durable power of attorney for medical decision?

Yes

No

Do you have a durable power of attorney for financial decision?

Yes

No

(If someone other than you administers your finances and/or obligations, please list this 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.)

Row Start

Responsible Party/Financial:

Name

First

Address

Street Address City State / Province / Region ZIP / Postal Code

Work #:

Home #:

Cell:

Relationship:

Alternative/Secondary:

Name

First

Address

Street Address City State / Province / Region ZIP / Postal Code

Work #:

Home #:

Cell:

Relationship:

Column Break

Responsible Party/Medical:

Name

First

Address

Street Address City State / Province / Region ZIP / Postal Code

Work #:

Home #:

Cell:

Relationship:

Alternative/Secondary:

Name

First

Address

Street Address City State / Province / Region ZIP / Postal Code

Work #:

Home #:

Cell:

Relationship:

Row End

General Preferences

Primary Physician:

First

Address:

Phone No:

Alternate/Specialist Physician:

First

Address:

Phone No:

Dentist Physician:

First

Address:

Phone No:

Ophthamologist Physician:

First

Address:

Phone No:

Hospital:

First

Address:

Phone No:

Podiatrist:

First

Address:

Phone No:

Pharmacy:

First

Address:

Phone No:

Mortuary:

First

Address:

Phone No:

Insurance Information

Social Security No:

Hospital Stay Dates:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Medicare A No:

Medicare B No:

Other Insurance:

1) Name & Policy No:

2) Name & Policy No:

Veteran:

Yes

No

Spouse:

Yes

No

Child:

Yes

No

Policy No:

Financial Data

The information is Strictly Confidential

Assets: Total Assets....(Including Checking, Savings, Stocks, Bonds, Investments, Real Estate)

Total(Required)

Liabilities: Total Liabilities....(Including Credit Cards, Mortgage and Loans)

Total(Required)

Monthly Income: Total Monthly Income....(Including Social Security, Pension, Interest Income and Royalties)

Total(Required)

I (we) make this application for residence of my (our) own free will and accord. I (we) declare the information provided to the foregoing questions to be true, complete and an accurate financial account to the best of my (our) knowledge as of the date written below. i (we) authorize and request that my (our) attending physician, surgeon or other person having direct, professional knowledge on my (our) physical or mental health (past or present) provide to the staff at the Catholic Care Center any and all information relative here. Any false or misleading information will void the application approval and/or resident agreement.

Applicant's Consent(Required)

I Agree

By selecting "Agree" you hereby give your consent.

Date

MM slash DD slash YYYY

Second Applicant's Consent

I Agree

By selecting "Agree" you hereby give your consent.

Date

MM slash DD slash YYYY

Guardian or Guarantor's Signature

I Agree

By selecting "Agree" you hereby give your consent.

Date

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

Articles, Events, and Updates

Brain Games

A fun activity time for residents to sharpen their mental skills. Family members are also welcome.
Bingo

It’s game time! The traditional game of Bingo. Prizes will be handed out! Located in the West Wing room.
Exercise Class

A group exercise class offered to residents. The workout includes light, overall body movement, and stretching.
Brain Games

A fun activity time for residents to sharpen their mental skills. Family members are also welcome.
Bingo

It’s game time! The traditional game of Bingo. Prizes will be handed out! Located in the West Wing room.
Exercise Class

A group exercise class offered to residents. The workout includes light, overall body movement, and stretching.
Brain Games

A fun activity time for residents to sharpen their mental skills. Family members are also welcome.
Bingo

It’s game time! The traditional game of Bingo. Prizes will be handed out! Located in the West Wing room.
Exercise Class

A group exercise class offered to residents. The workout includes light, overall body movement, and stretching.
Brain Games

A fun activity time for residents to sharpen their mental skills. Family members are also welcome.

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St. Veronica Behavioral Health Hospital

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6700 E 45th St N

Bel Aire, KS 67226

(316) 744-2020

Join Our Team

Schedule A Tour

Become A Resident

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