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PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES It includes any person who is unable, or likely to be unable, to physically and mentally respond to a sensory signal approved by the State Fire Marshal, or to an oral instruction relating to fire danger, and persons who depend upon mechanical aids such as crutches, walkers, and wheelchairs
I hereby authorize release of medical information in this report to the . . . PATIENT'S DIAGNOSIS (To be completed by the physician) NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a residential care facility for the elderly licensed by the Department of Social Services
PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES It includes any person who is unable, or likely to be unable, to physically and mentally respond to a sensory signal approved by the State Fire Marshal, or an oral instruction relating to fire danger, and persons who depend upon mechanical aids such as crutches, walkers, and wheelchairs
hereby authorize release of medical information in this report to the . . . PATIENT'S DIAGNOSIS (To be completed by the physician) NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a residential care facility for the elderly licensed by the Department of Social Services
Form LIC602 Physicians Report for Community Care Facilities - California Form LIC 602, Physician's Report for Community Care Facilities, is a document completed by a health care professional (physician) to determine whether the resident or the applicant for admission to a Community Care Facility is appropriate for continued care in this facility or admission
Physician’s Report (California) - Bayshire Carlsbad NOTE TO PHYSICIAN: The person is either a resident or prospective resident of an assisted living facility Please complete all of the information below The information that you provide about this person is required by law to assist in determining whether the person is appropriate for care This is not a skilled nursing facility 2 SEX: 3
California Health Human Services Agency California Department of . . . I hereby authorize release of medical information in this report to the facility named above I acknowledge that by providing my electronic signature for this form, I agree my electronic signature is the legal binding equivalent to my handwritten signature
Physicians Report For Community Care Facilities (LIC 602) The purpose of the LIC 602 form is to collect information about an individual seeking admission or continued care in a residential care facility The California Department of Social Services uses the form to determine whether the individual is appropriate for such care