KIMBERLY HEALTH CENTER ADMISSION APPLICATION


You have contacted this nursing home and indicated a desire to be admitted as a patient to the facility. Because of this, you have already been issued a receipt indicating the date and time of your initial request and your name has been placed on our dated list of applications or inquiry list.

Please find enclosed this facility's written application form. As soon as you substantially complete and return the form to the facility, your name will be placed on our waiting list for admission to the facility. Your name will only be placed on our waiting list after you substantially complete and return this written application form to us.

 

PERSONAL INFORMATION

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RESPONSIBLE PARTY

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DOES ANYONE HOLD:


MEDICAL HISTORY


 


CONFIDENTIAL FINANCIAL INFORMATION


INSURANCE

APPLICANT'S ASSETS

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Fill out the appropriate form for admission to the Mary Wade Home.

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