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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 signature AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (TO BE COMPLETED BY PERSON’S AUTHORIZED REPRESENTATIVE) I hereby authorize the release of medical information contained in this report regarding the physical examination of:
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to the above-named Child Care Center.
PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) IV. PATIENT'S DIAGNOSIS (To be completed by the physician) I. FACILITY INFORMATION (To be completed by the licensee/designee) I hereby authorize release of medical information in this report to the facility named above. III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
SECTION II: PHYSICIAN OR LICENSED/CERTIFIED PSYCHOLOGIST INSTRUCTIONS AND CERTIFICATION The county welfare department needs your information to determine if the above-named person has a physical or mental incapacity that prevents or substantially reduces the patient’s ability to engage in
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF). NOTE TO PHYSICIAN:
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.
