Lic 627C – Fill Out and Use This PDF

The Lic 627C form, issued by the State of California's Health and Human Services Agency and the California Department of Social Services Community Care Licensing, is a critical document used to consent to emergency medical or dental care for adults and elderly individuals in residential facilities. It grants a designated facility the authority to make urgent medical decisions prescribed by a licensed physician, osteopath, or dentist to protect a client's health, potentially saving lives or preventing severe health complications. For anyone overseeing the care of adults or the elderly in such settings, understanding and completing this form is a key responsibility. Click the button below to learn more about how to properly fill out the Lic 627C form.

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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.

Question	Answer
Form Name	Lic 627C
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	lic 627c, LIC, OSTEOPATH, ENG

How to Fill Out Form Lic 627C

Form Lic 627C at a glance

What it is: Consent for Emergency Medical Treatment, Adult and Elderly Residential Facilities, is a form of the State of California Health and Human Services Agency, California Department of Social Services, Community Care Licensing.

Who signs: The client, authorized representative or conservator gives consent.

A filled-in Form Lic 627C example: a client completes the emergency consent

Form Lic 627C example filled out, example: a client completes the emergency consent — Anna Sample, a client, completes the emergency medical treatment consent. She is allergic to penicillin, lives at one address and has only a work phone. The picture shows the filled lines; its names and figures are sample values. The facility name, date and signature are left blank because the fillable file has no named field for them, and HOME PHONE is left blank because the client has only a work phone.

How to fill out Form Lic 627C, box by box

Facility name and name

Write the FACILITY NAME on the line to provide all emergency medical or dental care.

Write the name of the individual after FOR: the care is prescribed by a duly licensed physician (M.D.), osteopath (D.O.) or dentist (D.D.S.), and this care may be given under whatever conditions are necessary to preserve the life, limb or well being of the individual named.

Medication allergies, date and signature

Enter the medication allergies of the client.

Enter the date and the client, authorized representative or conservator signature, and circle the appropriate title.

Home address, home phone and work phone

Write the home address under HOME ADDRESS.

Enter the home phone and the work phone.

Sources

[1] Form Lic 627C (4/00), Consent for Emergency Medical Treatment, Adult and Elderly Residential Facilities, California Department of Social Services (the Official source link on this page).