Are you familiar with the Lic 601 form? If not, this post is for you! This document is an important filing requirement for any business that anticipates establishing a Long-Term Care Insurance (LTCI) policy. In it, companies provide state regulators with an overview of their plan and how they will operate in order to ensure compliance under the law. Here, we'll discuss everything from what exactly is included on the form to where and when to file it. After reading this blog post, you'll have all the knowledge needed to correctly submit your company's 601 form in no time!
| Question | Answer |
|---|---|
| Form Name | Lic 601 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | human lic 601, lic 600, lic 601, lic 601 rcfe |
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
IDENTIFICATION AND EMERGENCY INFORMATION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
This information is required under the H & S Code and the regulations of the Department to be maintained on every person admitted to a community care facility, to be readily available to the person in charge, but not accessible to unauthorized persons. All information must be kept current. See other side for additional information required for residential facilities for children.
A. ALL FACILITIES |
[EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700] |
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1. |
NAME OF CLIENT OR CHILD |
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SOCIAL SECURITY NUMBER (OPTIONAL) |
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DATE OF BIRTH |
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AGE |
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SEX |
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2. |
RESPONSIBLE PERSON OR PLACEMENT AGENCY |
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ADDRESS |
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TELEPHONE |
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3. |
NAME OF NEAREST RELATIVE (OPTIONAL) |
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RELATIONSHIP |
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ADDRESS |
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TELEPHONE |
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4. |
DATE ADMITTED TO FACILITY |
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ADDRESS PRIOR TO ADMISSION |
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5. |
DATE LEFT |
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FORWARDING ADDRESS |
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6. |
REASONS FOR LEAVING FACILITY |
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7. |
PERSON(S) RESPONSIBLE FOR FINANCIAL AFFAIRS, PAYMENT FOR CARE, LEGAL GUARDIAN, IF ANY |
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NAME |
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ADDRESS |
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TELEPHONE |
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8. |
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OTHER PERSONS TO BE NOTIFIED IN EMERGENCY |
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a. |
PHYSICIAN |
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b. |
MENTAL HEALTH PROVIDER, IF ANY |
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c. |
DENTIST |
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d. |
RELATIVE(S) |
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e. |
FRIEND(S) |
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9. |
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EMERGENCY HOSPITALIZATION PLAN |
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NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCY |
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ADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCY |
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MEDICAL PLAN |
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MEDICAL PLAN IDENTIFICATION NUMBER |
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NAME OF DENTAL PLAN (IF ANY) |
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DENTAL PLAN NUMBER (IF ANY) |
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10. |
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OTHER REQUIRED INFORMATION |
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a.AMBULATORY STATUS
b. RELIGIOUS PREFERENCE |
NAME AND ADDRESS OF CLERGYMAN OR RELIGIOUS ADVISOR, IF ANY |
TELEPHONE |
( )
11. COMMENTS
SIGNATURE OF RESIDENT
SIGNATURE OF PERSON COMPLETING FORM
TITLE
DATE
LIC 601 (8/08) Personal |
Page 1 of 2 |
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B.RESIDENTIAL FACILITIES FOR CHILDREN
(Additional information is required by regulation for residential facilities for children.)
1.NAME OF CHILD
2. NAME AND ADDRESS OF PERSON TO CONTACT, IF AUTHORIZED REPRESENTATIVE IS NOT AVAILABLE |
SPECIFY RELATIONSHIP |
TELEPHONE NUMBER |
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3. NAME AND ADDRESS OF PARENT(S)/PARENT’S DOMESTIC PARTNER, IF KNOWN |
TELEPHONE NUMBER |
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4.CHILD’S COURT STATUS (ATTACH CUSTODY ORDERS AND AGREEMENTS WITH PARENT(S), OR PERSON(S) HAVING LEGAL CUSTODY. NOTE: OPTIONAL FOR SMALL FAMILY AND FOSTER FAMILY HOMES)
5. |
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PERSON(S) WITH WHOM CHILD HAS BEEN LIVING (IF KNOWN) |
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NAME AND RELATIONSHIP |
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ADDRESS |
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TELEPHONE |
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6. |
VISITATION RESTRICTIONS (BY COURT ORDER OR AUTHORIZED REPRESENTATIVE) |
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PERSON(S) NOT AUTHORIZED TO VISIT CHILD |
PERSON(S) NOT AUTHORIZED TO VISIT CHILD |
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NAME |
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RELATIONSHIP |
NAME |
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RELATIONSHIP |
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7. |
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FAMILY RESIDENCE VISITATION RESTRICTIONS |
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SPECIFY, IF ANY |
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8. |
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ALL PERSONS AUTHORIZED TO REMOVE CHILD FROM HOME |
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NAME
RELATIONSHIP
SPECIFY CONDITIONS
9. |
TELEPHONE ACCESS |
MAKE AND RECEIVE CONFIDENTIAL CALLS
■ YES |
■ NO (BY COURT ORDER) |
IF NO, SPECIFY RESTRICTIONS
10.COMMENTS
LIC 601 (8/08) Personal |
Page 2 of 2 |