Lic 622 Form PDF Details

Are you a property manager wondering what is the Lic 622 Form? This form is an important document related to tenant eviction in Massachusetts. It serves as a notice to tenants that their lease has been terminated and they must vacate the property within 30 days. Understanding both your rights and responsibilities under this form can go a long way in ensuring compliance with the relevant regulations, so make sure you take time to decipher its contents carefully. In this blog post, we will outline the components of Lic 622 Form and answer your pressing questions about it!

QuestionAnswer
Form NameLic 622 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslic 622 form, lic 622 centrally stored, centrally stored medication, centrally stored medication record

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

CENTRALLY STORED MEDICATION AND DESTRUCTION RECORD

I. CENTRALLY STORED MEDICATION

INSTRUCTIONS: Centrally stored medications shall be kept in a safe and locked place that is not accessible to any person(s) except authorized individuals. Medication records on each client/resident shall be maintained for at least one year.

FACILITY NAME

FACILITY NUMBER

NAME

(LAST

FIRST

MIDDLE)

ADMISSION DATE

ATTENDING PHYSICIAN

ADMINISTRATOR

MEDICATION NAME

STRENGTH/

QUANTITY

INSTRUCTIONS

CONTROL/CUSTODY

EXPIRATION

DATE

DATE

FILLED

DATE

STARTED

PRESCRIBING

PHYSICIAN

PRESCRIPTION

NUMBER

NO. OF

REFILLS

NAME OF

PHARMACY

LIC 622 (3/99) (CONFIDENTIAL)

MEDICATION NAME

STRENGTH/

QUANTITY

INSTRUCTIONS

CONTROL/CUSTODY

EXPIRATION

DATE

DATE

FILLED

DATE

STARTED

PRESCRIBING

PHYSICIAN

PRESCRIPTION NO. OF

NUMBER REFILLS

NAME OF

PHARMACY

II. MEDICATION DESTRUCTION RECORD

INSTRUCTIONS: Prescription drugs not taken with the client/resident upon termination of services or otherwise disposed of shall be destroyed in the facility by the Administrator or

Designated

Representative and witnessed by one other adult who is not a client/resident. All facilities except Residential Care Facilities for the Elderly (RCFEs) shall

retain destruction

records for at least one year. RCFEs shall retain records for at least three years.

 

 

MEDICATION NAME

STRENGTH/

QUANTITY

DATE FILLED

PRESCRIPTION DISPOSAL

NUMBERDATE

NAME OF PHARMACY

SIGNATURE OF ADMINISTRATOR OR

DESIGNATED REPRESENTATIVE

SIGNATURE OF WITNESS

ADULT NON-CLIENT

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As for the blanks of this particular document, here's what you should consider:

1. When completing the lic 622 destruction record, make sure to incorporate all of the essential blank fields within the associated area. It will help to facilitate the work, enabling your details to be handled fast and accurately.

Find out how to complete centrally stored medication record portion 1

2. Immediately after this part is filled out, proceed to type in the applicable details in these: LIC CONFIDENTIAL.

Stage number 2 of completing centrally stored medication record

People frequently get some points incorrect while filling in LIC CONFIDENTIAL in this area. You need to review what you enter right here.

3. This stage is normally straightforward - fill out all of the empty fields in MEDICATION NAME, QUANTITY, CONTROLCUSTODY, DATE, FILLED, STARTED, PHYSICIAN, NUMBER, REFILLS, and PHARMACY to complete this process.

Filling in section 3 of centrally stored medication record

4. The next paragraph needs your attention in the following parts: MEDICATION NAME, QUANTITY, DATE FILLED, NUMBER, DATE, NAME OF PHARMACY, SIGNATURE OF ADMINISTRATOR OR, SIGNATURE OF WITNESS, DESIGNATED REPRESENTATIVE, and ADULT NONCLIENT. Just remember to enter all of the needed information to go forward.

Completing part 4 in centrally stored medication record

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