Form LIC601 "Identification and Emergency Information" - California

What Is LIC 601 Form?

Form LIC 601, Identification and Emergency Information, is a legal document that contains the personal details of every individual admitted to a community care facility. It is typically filled out when an individual is admitted to a facility to establish all of the necessary details about the resident and a contact person that may be reached if the resident gets involved in an emergency situation. The information stated in the form must be kept current and made available to community care facility employees. Make copies for relatives, caretakers, physicians - anyone who is periodically responsible for the child.

This form was released by the California Department of Social Services (CDSS), a component of the California Health and Human Services Agency (CHHS). The latest version of the form was issued on August 1, 2008, with all previous editions obsolete. You can download a fillable LIC 601 Form through the link below.

Form LIC 601 (SP), Identificación e Información de Emergencia (the Spanish version of LIC 601 Form) can also be found on our website. If an individual is submitting to a child care center or family child care home, complete Form LIC 700, Identification and Emergency Information (Child Care Centers/Family Child Care Homes).

ADVERTISEMENT

Form LIC 601 Instructions

Enter the following details on the LIC 601 Form:

  1. Personal details of the client - name, social security number, date of birth, age, sex. State the details of a responsible individual or placement agency. Also, make sure it is possible to identify the nearest relative. Indicate the date of admission. Once the individual is discharged, write down the date of discharge and reasons for leaving the facility.
  2. Person(s) responsible for financial affairs and payments. Add the full name, address, and telephone number of the individual to be contacted in various circumstances, for instance, the legal guardian.
  3. Other persons to be notified in an emergency. Provide the personal details of the physician, mental health provider, dentist, relatives, and friends who must be contacted.
  4. Emergency hospitalization plan. Name the hospital to be taken to in case of an emergency and provide information about medical and dental plans.
  5. Other required information. State the ambulatory status and religious preference.
  6. Signatures of the resident and the person who completes the form. Write down the actual date.
  7. Residential facilities for children require additional information. State the name of the child, identify the person to contact in case of an emergency, and specify their relationship. Indicate the person(s) with whom the child has been living and any person(s) not authorized to visit the child. Provide personal details of the persons authorized to remove the child from home and specify restrictions on telephone access.
ADVERTISEMENT

Download Form LIC601 "Identification and Emergency Information" - California

Download PDF

Fill PDF online

Rate (4.5 / 5) 88 votes
STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
This information is required under the H & S Code and the regulations
of the Department to be maintained on every person admitted to a
IDENTIFICATION AND
community care facility, to be readily available to the person in charge,
EMERGENCY INFORMATION
but not accessible to unauthorized persons. All information must be
kept current. See other side for additional information required for
residential facilities for children.
A. ALL FACILITIES
[EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700]
1. NAME OF CLIENT OR CHILD
SOCIAL SECURITY NUMBER (OPTIONAL)
DATE OF BIRTH
AGE
SEX
2. RESPONSIBLE PERSON OR PLACEMENT AGENCY
ADDRESS
TELEPHONE
(
)
3. NAME OF NEAREST RELATIVE (OPTIONAL)
RELATIONSHIP
ADDRESS
TELEPHONE
(
)
4. DATE ADMITTED TO FACILITY
ADDRESS PRIOR TO ADMISSION
5. DATE LEFT
FORWARDING ADDRESS
6. REASONS FOR LEAVING FACILITY
PERSON(S) RESPONSIBLE FOR FINANCIAL AFFAIRS, PAYMENT FOR CARE, LEGAL GUARDIAN, IF ANY
7.
NAME
ADDRESS
TELEPHONE
(
)
(
)
(
)
OTHER PERSONS TO BE NOTIFIED IN EMERGENCY
8.
NAME
ADDRESS
TELEPHONE
a.
PHYSICIAN
(
)
b.
MENTAL HEALTH PROVIDER, IF ANY
(
)
c.
DENTIST
(
)
d.
RELATIVE(S)
(
)
e.
FRIEND(S)
(
)
EMERGENCY HOSPITALIZATION PLAN
9.
NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCY
ADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCY
MEDICAL PLAN
MEDICAL PLAN IDENTIFICATION NUMBER
NAME OF DENTAL PLAN (IF ANY)
DENTAL PLAN NUMBER (IF ANY)
OTHER REQUIRED INFORMATION
10.
a.
AMBULATORY STATUS
b.
RELIGIOUS PREFERENCE
NAME AND ADDRESS OF CLERGYMAN OR RELIGIOUS ADVISOR, IF ANY
TELEPHONE
(
)
11. COMMENTS
SIGNATURE OF RESIDENT
SIGNATURE OF PERSON COMPLETING FORM
TITLE
DATE
Page 1 of 2
LIC 601 (8/08) Personal
STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
This information is required under the H & S Code and the regulations
of the Department to be maintained on every person admitted to a
IDENTIFICATION AND
community care facility, to be readily available to the person in charge,
EMERGENCY INFORMATION
but not accessible to unauthorized persons. All information must be
kept current. See other side for additional information required for
residential facilities for children.
A. ALL FACILITIES
[EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700]
1. NAME OF CLIENT OR CHILD
SOCIAL SECURITY NUMBER (OPTIONAL)
DATE OF BIRTH
AGE
SEX
2. RESPONSIBLE PERSON OR PLACEMENT AGENCY
ADDRESS
TELEPHONE
(
)
3. NAME OF NEAREST RELATIVE (OPTIONAL)
RELATIONSHIP
ADDRESS
TELEPHONE
(
)
4. DATE ADMITTED TO FACILITY
ADDRESS PRIOR TO ADMISSION
5. DATE LEFT
FORWARDING ADDRESS
6. REASONS FOR LEAVING FACILITY
PERSON(S) RESPONSIBLE FOR FINANCIAL AFFAIRS, PAYMENT FOR CARE, LEGAL GUARDIAN, IF ANY
7.
NAME
ADDRESS
TELEPHONE
(
)
(
)
(
)
OTHER PERSONS TO BE NOTIFIED IN EMERGENCY
8.
NAME
ADDRESS
TELEPHONE
a.
PHYSICIAN
(
)
b.
MENTAL HEALTH PROVIDER, IF ANY
(
)
c.
DENTIST
(
)
d.
RELATIVE(S)
(
)
e.
FRIEND(S)
(
)
EMERGENCY HOSPITALIZATION PLAN
9.
NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCY
ADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCY
MEDICAL PLAN
MEDICAL PLAN IDENTIFICATION NUMBER
NAME OF DENTAL PLAN (IF ANY)
DENTAL PLAN NUMBER (IF ANY)
OTHER REQUIRED INFORMATION
10.
a.
AMBULATORY STATUS
b.
RELIGIOUS PREFERENCE
NAME AND ADDRESS OF CLERGYMAN OR RELIGIOUS ADVISOR, IF ANY
TELEPHONE
(
)
11. COMMENTS
SIGNATURE OF RESIDENT
SIGNATURE OF PERSON COMPLETING FORM
TITLE
DATE
Page 1 of 2
LIC 601 (8/08) Personal
B.
RESIDENTIAL FACILITIES FOR CHILDREN
(Additional information is required by regulation for residential facilities for children.)
1.
NAME OF CHILD
2.
NAME AND ADDRESS OF PERSON TO CONTACT, IF AUTHORIZED REPRESENTATIVE IS NOT AVAILABLE
SPECIFY RELATIONSHIP
TELEPHONE NUMBER
(
)
3.
NAME AND ADDRESS OF PARENT(S)/PARENT’S DOMESTIC PARTNER, IF KNOWN
TELEPHONE NUMBER
(
)
4. CHILD’S COURT STATUS (ATTACH CUSTODY ORDERS AND AGREEMENTS WITH PARENT(S), OR PERSON(S) HAVING LEGAL CUSTODY. NOTE: OPTIONAL FOR SMALL FAMILY AND FOSTER FAMILY HOMES)
PERSON(S) WITH WHOM CHILD HAS BEEN LIVING (IF KNOWN)
5.
NAME AND RELATIONSHIP
ADDRESS
TELEPHONE
(
)
(
)
(
)
6.
VISITATION RESTRICTIONS (BY COURT ORDER OR AUTHORIZED REPRESENTATIVE)
PERSON(S) NOT AUTHORIZED TO VISIT CHILD
PERSON(S) NOT AUTHORIZED TO VISIT CHILD
NAME
RELATIONSHIP
NAME
RELATIONSHIP
FAMILY RESIDENCE VISITATION RESTRICTIONS
7.
SPECIFY, IF ANY
ALL PERSONS AUTHORIZED TO REMOVE CHILD FROM HOME
8.
NAME
RELATIONSHIP
SPECIFY CONDITIONS
TELEPHONE ACCESS
9.
IF NO, SPECIFY RESTRICTIONS
MAKE AND RECEIVE CONFIDENTIAL CALLS
■ ■
■ ■
YES
NO (BY COURT ORDER)
10.
COMMENTS
LIC 601 (8/08) Personal
Page 2 of 2
Page of 2