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This version of the form is not currently in use and is provided for reference only. Download this version of
Form LIC605A
for the current year.
Form LIC605A Release of Client / Resident Medical Information - California
What Is Form LIC605A?
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.
FAQ
Q: What is Form LIC605A?
A: Form LIC605A is a Release of Client/Resident Medical Information form in California.
Q: What is the purpose of Form LIC605A?
A: The purpose of Form LIC605A is to authorize the release of medical information of a client/resident in California.
Q: Who needs to fill out Form LIC605A?
A: Form LIC605A needs to be filled out by the client/resident or their authorized representative.
Q: What information is required on Form LIC605A?
A: Form LIC605A requires the client/resident's name, date of birth, and signature, as well as the name and contact information of the person/organization authorized to receive the medical information.
Q: Is Form LIC605A specific to California?
A: Yes, Form LIC605A is specific to California and should be used for requesting the release of medical information within the state.
Q: Is there a fee for submitting Form LIC605A?
A: There is usually no fee for submitting Form LIC605A, but it is best to check with the specific healthcare facility/hospital for any possible charges.
Form Details:
- Released on May 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 LIC605A by clicking the link below or browse more documents and templates provided by the California Department of Social Services.
