Get Beikirch Fillable Application Form

The Beikirch Fillable Application Form is a crucial document for individuals seeking admission to Lakeside Beikirch Care Center. This guide provides step-by-step instructions on how to complete the form online accurately and efficiently.

Follow the steps to successfully fill out the online application form.

1. Click the ‘Get Form’ button to obtain the Beikirch Fillable Application Form and open it in your preferred online editor.
2. Fill in the personal details of the applicant, including their name, address, city, state, phone number, and date of birth. Ensure that all fields are completed accurately.
3. Indicate whether the applicant is a U.S. citizen by selecting 'Yes' or 'No'. Include their birthplace and marital status. If the applicant has a maiden name, provide that information as well.
4. Answer the question regarding any relatives or friends who have previously resided at Lakeside Beikirch. If applicable, provide their names.
5. Complete the section about the applicant's military status, occupation, education, and religious affiliation. Include the name and contact information of their clergy, physician, and dentist.
6. Input the details for the person to contact regarding admission, including their name, relationship to the applicant, and all relevant contact information.
7. For the Durable Power of Attorney and Health Care Proxy sections, provide the names and contact information of the relevant individuals, indicating whether the documents have been executed.
8. List emergency contacts in the specified format, providing names, relationships, and multiple phone numbers for each individual listed.
9. Fill out the insurance information section, including social security number, Medicare and Medicaid details, and any health insurance information available.
10. In the financial information section, provide details of the applicant's income, assets, and any real estate or property ownership.
11. Outline the applicant's medical history and discharge plans, ensuring to include any relevant medical issues or allergies.
12. Complete the funeral arrangements section, and confirm whether a pre-need burial account has been established and its revocability.
13. Finally, ensure that the form is signed and dated by the individual completing it, indicating their relationship to the applicant. Review all information for accuracy.
14. Once all sections of the form are completed, save any changes, and download, print, or share the form as needed.

Complete your application online today to ensure timely processing of your admission request.