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LICENSEE MUST REPORT THE DEATH OF A CLIENT OF ANY CAUSE, REGARDLESS OF WHERE THE DEATH OCCURRED. INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. RETAIN COPY OF REPORT IN CLIENT’S FILE. MEDICAL TREATMENT NECESSARY?
23 mar 2021 · Submitting notification with an attached death certificate using one of the Notice of Death forms below satisfies these reporting requirements under State law. Please complete the appropriate form with the most current information, review it for accuracy and submit them only once.
LIC 602 (7/22) - Physician's Report For Community Care Facilities ; LIC 602A (8/11) - Physician's Report For Residential Care Facilities For The Elderly (RCFE) LIC 603 (6/22) - Preplacement Appraisal Information ; LIC 603A (7/99) - Resident Appraisal ; LIC 604 (10/05) - Admission Agreement Guide For Residential Facilities
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I hereby authorize release of medical information in this report to the facility named above. 1. SIGNATURE OF RESIDENT AND/OR RESIDENT'S LEGAL REPRESENTATIVE. 2. ADDRESS 3. DATE. IV. PATIENT'S DIAGNOSIS (To be completed by the physician)
death report licensee must report the death of a client of any cause, regardless of where the death occurred. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. submit written report within 7 days of occurrence. retain copy of report in client’s file. name of facility facility file ...
This form obligates the responsible entities to report the demise of a client to relevant authorities and entities by the next working day, followed by a detailed written report within seven days.
Fill out and download the LIC624A Death Report form in California. Create a PDF version or fill it out online and save as a ready-to-print PDF. Completely free to use.
