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LIC 605A: Release of Client/Resident Medical Information

By Sevana Care · Checked against cdss.ca.gov and Title 22 on

When it is due
The form and § 87506 give no deadline [1][3].The form leaves the end date to the person who authorizes the release: "This authorization shall expire on" [1].
Who fills it out
The form does not say who in the home fills in the blanks [1].Its bottom lines are for the "Client or Authorized Representative", the relationship to the person and an address [1]. It is addressed "To" a provider, such as a physician, clinic or hospital, and names the facility, person or agency requesting the information [1].
Where it is kept
Note 3 on the form: "Licensees should maintain a copy of this form in the facility records" [1].Section 87506(a) requires a record for each resident, in the facility or at a central administrative location readily available to facility and licensing staff [3]. CDSS's list of records an RCFE keeps (LIC 311F, 4/05) does not name LIC 605A [4].
How long to keep
Section 87506(e) sets a minimum of three years after service to the resident ends for original records [3].Section 87506 does not name LIC 605A [3].

LIC 605A is the California Department of Social Services (CDSS) Release of Client/Resident Medical Information, a one-page form [1]. The client or an authorized representative uses it to authorize a provider to "release any and all medical or confidential information contained in the record of" a named person. The form also names the facility, person or agency requesting the information [1]. The form does not name a type of facility. Its note 3 says "This information is required to conform to CCR Title 22 regulations" and "Licensees should maintain a copy of this form in the facility records" [1]. Title 22 § 87506(c)(1) covers the licensee revealing a resident's information. It requires "the resident's written consent or that of his designated representative" and names no form [3].

Who fills it out

The form has three lines at the bottom, for the person who authorizes the release [1]:

  • "Client or Authorized Representative"
  • the relationship to the person whom information is requested about
  • the address

The top of the form is addressed "To" a provider. The form lists examples: "Physician, Clinic, Hospital, Hospice, Home Health Agency, Attending Nurse, Psychologist, Counselor, Therapist, etc." It asks for that provider's address and a date [1]. Below, it asks for the name of the person whose record is released and the "Name and Address of Facility, Person or Agency Requesting Information" [1].

The form does not say who in the home fills in the blanks [1].

When it is due

The form and the rule set no date or number of days. Neither the form nor § 87506 says when to collect a release [1][3].

The rule ties the home's own disclosures to consent. Section 87506(c)(1) is about the licensee, and the form is addressed to a provider [1][3]. Section 87506(c)(1): "The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative" [3]. Section 87506(c): "All information and records obtained from or regarding residents shall be confidential" [3].

The form leaves the end date to the person who authorizes the release. The form says "This authorization shall expire on:" and leaves a blank for the date [1]. Note 1 says "The person who authorized this release may revoke this authorization at any time" [1].

Where it is kept

Note 3 on the form says "Licensees should maintain a copy of this form in the facility records" [1]. Note 2 says the person who authorized the release "has a right to receive a copy of the release" [1].

Section 87506(a) requires a record for each resident, in the facility or at a central administrative location readily available to facility staff and to licensing agency staff [3].

Resident records are confidential. The licensee is responsible for storing them and safeguarding what they contain [3].

How long to keep it. Section 87506(e): "Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident" [3]. Section 87506 does not name LIC 605A [3].

What the record must show

What the form asks [1]:

  • the provider's name and address
  • the date
  • the name of the person whose record is released
  • the name and address of the facility, person or agency requesting the information
  • the end date
  • the relationship and address on the bottom lines

What the form releases. "Any and all medical or confidential information contained in the record of" the named person [1]. The form has no line to narrow the kind of record or the dates it covers [1].

What the notes say. There are four [1]:

  1. The person who authorized the release may revoke it at any time.
  2. That person has a right to receive a copy.
  3. "This information is required to conform to CCR Title 22 regulations, to ensure a continuum of care to the resident, client or child. Licensees should maintain a copy of this form in the facility records."
  4. "The above facility is licensed by the Department of Social Services (or its accredited agencies), and does not provide skilled nursing care."

What the form leaves out. Below the bottom lines, the form has no line for a date of signing, though it has a "Date" line at the top beside the provider [1]. It cites no law other than "CCR Title 22" [1].

Questions

Does an RCFE have to use LIC 605A?

No source here says an RCFE must use it. The form does not name RCFEs, and its note 3 says the information "is required to conform to CCR Title 22 regulations" without citing a section [1]. A CDSS forms request for RCFEs, LIC 183B (10/03), lists it [5], but LIC 311F does not [4]. For the home's own disclosures, § 87506(c)(1) requires written consent and names no form [3], and § 87102, the Chapter 8 list of forms, does not include LIC 605A [6].

Is LIC 605A for the home to get records, or to release them?

The form does not say whether a home can use it to release its own records, and § 87506 does not say so either [1][3]. The form is addressed to a provider and names a requester [1]. Section 87506(c)(1) is about the licensee revealing a resident's information [3].

Is LIC 605A only for RCFEs?

No. Its title says "Client/Resident," note 3 says "resident, client or child," and the form names no facility type [1].

How long does the release last?

It lasts until the date on its "expire" line, which the person who authorizes the release fills in. Note 1 says that person may revoke it at any time [1]. Section 87506 gives no period [3].

Can a representative authorize the release?

The first bottom line reads "Client or Authorized Representative" [1]. The form does not say who counts as an authorized representative [1].

Does a release replace the medical assessment, LIC 602A?

No source says so. Section 87458(a) requires the licensee to obtain "documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year" before a person becomes a resident [7]. LIC 605A does not mention it [1].

More in Admission and the resident file

  • LIC 603A: The appraisal you complete before a resident moves in
  • LIC 9172: The checklist of what a new resident can do for themselves
  • LIC 625: A CDSS form you may use for the plan of action when a resident's need is not being met
  • LIC 604A: The CDSS guide for the admission agreement you sign with each resident
  • LIC 613C-2: The personal rights a resident signs at admission

Sources

  1. CDSS, LIC 605A (7/22), Release Of Client/Resident Medical Information (PDF)
  2. CDSS, Forms and Publications (I-L)
  3. California Code of Regulations, Title 22, § 87506, Resident Records (Westlaw)
  4. CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
  5. CDSS, Notice of Form Change No. 04-064 (2/27/2004), with LIC 183B (10/03) Forms Request, Residential Care Facilities For The Elderly (PDF)
  6. California Code of Regulations, Title 22, § 87102, Descriptions of Forms (Westlaw)
  7. California Code of Regulations, Title 22, § 87458, Medical Assessment (Westlaw)
  8. CDSS, LIC 601 (8/08), Identification And Emergency Information (PDF)