Lic 627C PDF Details

The Lic 627C form, issued by the California Department of Social Services within the Health and Human Services Agency, plays a crucial role in ensuring the safety and well-being of adults and the elderly in residential facilities. It serves as a formal consent document that authorizes medical or dental care in emergency situations, delineating the powers granted to facilities to seek immediate and necessary treatment for individuals under their care. This consent, pivotal in scenarios where time-sensitive decisions need to be made, is provided by either the client themselves, their authorized representative, or conservator. The form explicitly requires the identification of any medication allergies the individual has, thereby safeguarding against potential adverse reactions. Recognizing the gravity of its contents, the form also mandates the inclusion of contact details to ensure seamless communication. The Lic 627C embodies a critical safety net, affirming the commitment to maintaining the health and preserving the dignity of those in adult and elderly residential facilities.

QuestionAnswer
Form NameLic 627C
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslic 627c, LIC, OSTEOPATH, ENG

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

CONSENT FOR EMERGENCY MEDICAL TREATMENT-

Adult and Elderly Residential Facilities

AS THE CLIENT, AUTHORIZED REPRESENTATIVE OR CONSERVATOR, I HEREBY GIVE CONSENT TO

_________________________________________ TO PROVIDE ALL EMERGENCY MEDICAL OR DENTAL CARE

FACILITY NAME

PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR

__________________________________________________ . THIS CARE MAY BE GIVEN UNDER WHATEVER

NAME

CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE INDIVIDUAL NAMED ABOVE.

CLIENT HAS THE FOLLOWING MEDICATION ALLERGIES:

DATE

CLIENT/AUTHORIZED REPRESENTATIVE/CONSERVATOR SIGNATURE

 

(CIRCLE APPROPRIATE TITLE)

HOME ADDRESS

HOME PHONE

( )

WORK PHONE

( )

LIC 627C (ENG/SP) (4/00) (CONFIDENTIAL)

How to Edit Lic 627C Online for Free

This PDF editor makes it simple to create documents. It's not necessary to perform much to enhance ENG files. Merely try out these actions.

Step 1: Select the orange "Get Form Now" button on the following webpage.

Step 2: Now it's easy to change the Residential. Our multifunctional toolbar allows you to include, delete, transform, and highlight content material or perhaps undertake other commands.

These particular segments will help make up your PDF form:

completing OSTEOPATH part 1

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Step 4: Prepare no less than two or three copies of the form to keep clear of any specific future problems.

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