Form LIC602 "Physician's Report for Community Care Facilities" - California

What Is Form LIC 602?

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. Community Care Facilities are licensed to provide round-the-clock non-medical residential care to adults and children in need of assistance. In California, it is possible to apply for residential care to receive personal services, supervision, rehabilitative therapy, medication and more. This document is completed by the patient's primary physician or the attending physician. Most health care professionals are familiar with this document; however, it is recommended to have the form filled out by the primary care physician who possesses in-depth knowledge of the potential resident. A comprehensive physician's report is the most important part of the resident assessment process that must be updated should any significant change in the patient's condition take place.

The latest version of the Form 602 LIC was issued by the California Department of Social Services in July 2011 with all previous editions obsolete. A fillable version of the form is available for download below.

Form LIC 602A, Physician's Report for Residential Care Facilities for the Elderly (RCFE) is a related form used specifically to obtain residential care for the elderly residents or prospective residents of care facilities. Just like LIC Form 602, it needs to contain patient's information, authorization for release of medical information, and patient's diagnosis (primary and secondary diagnosis, description of known diseases, allergies, and other conditions, physical health and mental condition status, ambulatory status, etc.) certified by the health care professional.

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Form LIC 602 Instructions

  1. Facility Information. This section must be filled out by the licensee/designee (usually, the employee of the Community Care Facility). Provide the name of the facility, its telephone number, address, the licensee's name, telephone number, and facility license number;
  2. Resident/Client Information. It is completed by the resident/representative/licensee. Write down the name of the resident/client, the telephone number and the address, the social security number, and the information on the next of kin and the person responsible for the resident/client's finances;
  3. Patient's Diagnosis. The physician has to fill out this section of the form. Indicate the diagnosis, age, height, weight, and sex of the resident. Write down the results of tuberculosis examination and mention any infectious/contagious diseases or allergies the resident/client has and if this individual is currently treated/receives any medication. State the ambulatory status of resident/client selecting one of the given options - ambulatory, nonambulatory, bedridden. Describe the patient's physical and mental health status and assess this individual's capacity for self-care. List medication that can be given to the resident/client and any prescribed medications this individual is currently taking. After that, sign and date the form, also providing your address and telephone number;
  4. Additionally, the document must be signed and dated by the individual's authorized representative who agrees to release the medical information contained in this report relating to the physical examination of the patient.
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Download Form LIC602 "Physician's Report for Community Care Facilities" - California

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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:
The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. These
types of facilities are currently responsible for providing the level of care and supervision, primarily nonmedical care, necessary
to meet the needs of the individual residents/clients.
THESE FACILITIES DO NOT PROVIDE PROFESSIONAL NURSING CARE.
The information that you complete on this person is required by law to assist in determining whether he/she is appropriate for
admission to or continued care in a facility.
FACILITY INFORMATION (To be completed by the licensee/designee)
NAME OF FACILITY:
TELEPHONE:
`
ADDRESS:
NUMBER
STREET
CITY
LICENSEE’S NAME:
TELEPHONE:
FACILITY LICENSE NUMBER:
RESIDENT/CLIENT INFORMATION (To be completed by the resident/authorized representative/licensee)
NAME:
TELEPHONE:
ADDRESS:
NUMBER
STREET
CITY
SOCIAL SECURITY NUMBER:
NEXT OF KIN:
PERSON RESPONSIBLE FOR THIS PERSON’S FINANCES:
PATIENT’S DIAGNOSIS (To be completed by the physician)
PRIMARY DIAGNOSIS:
SECONDARY DIAGNOSIS:
LENGTH OF TIME UNDER YOUR CARE:
AGE:
HEIGHT:
SEX:
WEIGHT:
IN YOUR OPINION DOES THIS PERSON REQUIRE SKILLED NURSING CARE?
■ ■
■ ■
YES
NO
TUBERCULOSIS EXAMINATION RESULTS:
DATE OF LAST TB TEST:
■ ■
■ ■
■ ■
ACTIVE
INACTIVE
NONE
TYPE OF TB TEST USED:
TREATMENT/MEDICATION:
■ ■
■ ■
YES
NO
If YES, list below:
OTHER CONTAGIOUS/INFECTIOUS DISEASES:
TREATMENT/MEDICATION:
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
A)
If YES, list below:
B)
If YES, list below:
TREATMENT/MEDICATION:
ALLERGIES
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
C)
If YES, list below:
D)
If YES, list below:
PAGE 1 OF 3
LIC 602 (7/11)
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:
The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. These
types of facilities are currently responsible for providing the level of care and supervision, primarily nonmedical care, necessary
to meet the needs of the individual residents/clients.
THESE FACILITIES DO NOT PROVIDE PROFESSIONAL NURSING CARE.
The information that you complete on this person is required by law to assist in determining whether he/she is appropriate for
admission to or continued care in a facility.
FACILITY INFORMATION (To be completed by the licensee/designee)
NAME OF FACILITY:
TELEPHONE:
`
ADDRESS:
NUMBER
STREET
CITY
LICENSEE’S NAME:
TELEPHONE:
FACILITY LICENSE NUMBER:
RESIDENT/CLIENT INFORMATION (To be completed by the resident/authorized representative/licensee)
NAME:
TELEPHONE:
ADDRESS:
NUMBER
STREET
CITY
SOCIAL SECURITY NUMBER:
NEXT OF KIN:
PERSON RESPONSIBLE FOR THIS PERSON’S FINANCES:
PATIENT’S DIAGNOSIS (To be completed by the physician)
PRIMARY DIAGNOSIS:
SECONDARY DIAGNOSIS:
LENGTH OF TIME UNDER YOUR CARE:
AGE:
HEIGHT:
SEX:
WEIGHT:
IN YOUR OPINION DOES THIS PERSON REQUIRE SKILLED NURSING CARE?
■ ■
■ ■
YES
NO
TUBERCULOSIS EXAMINATION RESULTS:
DATE OF LAST TB TEST:
■ ■
■ ■
■ ■
ACTIVE
INACTIVE
NONE
TYPE OF TB TEST USED:
TREATMENT/MEDICATION:
■ ■
■ ■
YES
NO
If YES, list below:
OTHER CONTAGIOUS/INFECTIOUS DISEASES:
TREATMENT/MEDICATION:
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
A)
If YES, list below:
B)
If YES, list below:
TREATMENT/MEDICATION:
ALLERGIES
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
C)
If YES, list below:
D)
If YES, list below:
PAGE 1 OF 3
LIC 602 (7/11)
Ambulatory status of client/resident:
■ ■
■ ■
Yes
No
1. This person is able to independently transfer to and from bed:
2.
For purposes of a fire clearance, this person is considered:
■ ■
■ ■
■ ■
Ambulatory
Nonambulatory
Bedridden
Nonambulatory: A person who is unable to leave a building unassisted under emergency conditions. 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.
Note: A person who is unable to independently transfer to and from bed, but who does not need assistance to turn or reposition in bed, shall be
considered non-ambulatory for the purposes of a fire clearance.
Bedridden: For the purpose of a fire clearance, this means a person who requires assistance with turning or repositioning in bed.
■ ■
■ ■
■ ■
COMMENTS:
I. PHYSICAL HEALTH STATUS:
GOOD
FAIR
POOR
YES
NO
ASSISTIVE DEVICE
COMMENTS:
(Check One)
1.
Auditory impairment
2.
Visual impairment
3.
Wears dentures
4.
Special diet
5.
Substance abuse problem
6.
Bowel impairment
7.
Bladder impairment
8.
Motor impairment
9.
Requires continuous bed care
■ ■
■ ■
■ ■
II. MENTAL HEALTH STATUS:
GOOD
FAIR
POOR
COMMENTS:
NO
OCCASIONAL
FREQUENT
IF PROBLEM EXISTS, PROVIDE COMMENT BELOW:
PROBLEM
1.
Confused
2.
Able to follow instructions
3.
Depressed
4.
Able to communicate
■ ■
■ ■
COMMENTS:
III. CAPACITY FOR SELF CARE:
YES
NO
YES
NO
COMMENTS:
(Check One)
1.
Able to care for all personal needs
2.
Can administer and store own medications
3.
Needs constant medical supervision
4.
Currently taking prescribed medications
5.
Bathes self
6.
Dresses self
7.
Feeds self
8.
Cares for his/her own toilet needs
9.
Able to leave facility unassisted
10. Able to ambulate without assistance
11. Able to manage own cash resources
PAGE 2 OF 3
LIC 602 (7/11)
PLEASE LIST OVER-THE-COUNTER MEDICATION THAT CAN BE GIVEN TO THE CLIENT/RESIDENT, AS NEEDED,
FOR THE FOLLOWING CONDITIONS:
CONDITIONS
OVER-THE-COUNTER MEDICATION(S)
1.
Headache
_____________________________________
2.
Constipation
_____________________________________
3.
Diarrhea
_____________________________________
4.
Indigestion
_____________________________________
5.
Others (specify condition)
_____________________________________
_________________________________________
_____________________________________
_________________________________________
_____________________________________
_________________________________________
PLEASE LIST CURRENT PRESCRIBED MEDICATIONS THAT ARE BEING TAKEN BY CLIENT/RESIDENT:
1.
________________________________
4.
_______________________________
7.
___________________________
2.
________________________________
5.
_______________________________
8.
___________________________
3.
________________________________
6.
_______________________________
9.
___________________________
PHYSICIAN’S NAME AND ADDRESS:
TELEPHONE:
DATE:
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:
PATIENT’S NAME:
TO (NAME AND ADDRESS OF LICENSING AGENCY):
ADDRESS:
SIGNATURE OF RESIDENT/POTENTIAL RESIDENT AND/OR HIS/HER AUTHORIZED
DATE:
REPRESENTATIVE
LIC 602 (7/11)
PAGE 3 OF 3
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