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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 LIC602
for the current year.
Form LIC602 Physician's Report for Community Care Facilities - California
What Is LIC 602 Form?
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.
The latest version of the Form 602 LIC was issued by the California Department of Social Services (CDSS) on July 1, 2011 , with all previous editions obsolete. A fillable version of the form is available for download below.
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.
Form LIC 602 Instructions
- 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.
- 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's/client's finances.
- 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 the 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.
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.
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.
Download Form LIC602 Physician's Report for Community Care Facilities - California
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