Form LIC627C "Consent for Emergency Medical Treatment - Adult and Elderly Residential Facilities" - California

What Is Form LIC627C?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2000;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LIC627C by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC627C "Consent for Emergency Medical Treatment - Adult and Elderly Residential Facilities" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Adult and Elderly Residential Facilities
AS THE CLIENT, AUTHORIZED REPRESENTATIVE OR CONSERVATOR, I HEREBY GIVE CONSENT TO
_________________________________________ TO PROVIDE ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________ . THIS CARE MAY BE GIVEN UNDER WHATEVER
NAME
CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE INDIVIDUAL NAMED
ABOVE.
CLIENT HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE
CLIENT/AUTHORIZED REPRESENTATIVE/CONSERVATOR SIGNATURE
(CIRCLE APPROPRIATE TITLE)
HOME ADDRESS
HOME PHONE
WORK PHONE
(
)
(
)
LIC 627C (ENG/SP) (4/00) (CONFIDENTIAL)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Adult and Elderly Residential Facilities
AS THE CLIENT, AUTHORIZED REPRESENTATIVE OR CONSERVATOR, I HEREBY GIVE CONSENT TO
_________________________________________ TO PROVIDE ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________ . THIS CARE MAY BE GIVEN UNDER WHATEVER
NAME
CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE INDIVIDUAL NAMED
ABOVE.
CLIENT HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE
CLIENT/AUTHORIZED REPRESENTATIVE/CONSERVATOR SIGNATURE
(CIRCLE APPROPRIATE TITLE)
HOME ADDRESS
HOME PHONE
WORK PHONE
(
)
(
)
LIC 627C (ENG/SP) (4/00) (CONFIDENTIAL)