Treatmentadult Details

The Lic 627C form is an important document for any business. This form allows businesses to pay their employees' wages and withholdings without having to worry about being penalized. The Lic 627C form must be filed on a quarterly basis, and it is important to make sure all information is accurate and up-to-date. Failing to file the Lic 627C form can lead to fines and other penalties from the government.

Here, you will discover a number of specifics of lic 627c PDF. This table can provide information about the form's length, completion duration, and the blanks you can be expected to fill.

QuestionAnswer
Form NameLic 627C
Form Length1 pages
Fillable?Yes
Fillable fields9
Avg. time to fill out2 min 3 sec
Other namesLIC, TREATMENTAdult, CONSERVATOR, fill out on line lic 627c eng sp 4 00 confidential

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

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completing  627C part 1

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