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LIC 627C: Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities

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

When it is due
The form carries no instructions about timing [1].Neither LIC 311F [3] nor Title 22 §§ 87506 and 87507 gives a deadline for it, and those two sections do not name it [5][6].
Who fills it out
The signer is "the client, authorized representative or conservator," who circles the appropriate title on the signature line [1].The form does not say who fills in the blanks [1].
Where it is kept
We found no source that says where a signed LIC 627C is kept.LIC 311F names it only in its form index, and its "Residents Records" list does not [3]. The form's footer reads "(CONFIDENTIAL)" [1].
How long to keep
Title 22 § 87506(e) sets "a minimum of three (3) years following termination of service to the resident" for original resident records, and the list of what a resident's record contains in § 87506(b) does not name this form [5].We found no retention period for LIC 627C itself.

LIC 627C is the California Department of Social Services (CDSS) form "Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities" [1][2]. On it, the client (resident), authorized representative or conservator consents to a named facility providing emergency medical or dental care that a licensed physician, osteopath or dentist prescribes [1]. CDSS lists LIC 627C in the form index of its list of records for RCFEs [3]. The Title 22 sections on resident records and admission agreements do not name it [5][6].

Who fills it out

The signer is "the client, authorized representative or conservator," and the signature line says "circle appropriate title" [1]. The form asks for the date, a home address, a home phone and a work phone without saying whose, and it does not say who fills in the blanks [1].

When it is due

LIC 627C is a signed consent. The form carries no instructions about timing, filing or retention. Its only date is beside the signature [1]. Neither LIC 311F [3] nor Title 22 §§ 87506 and 87507 gives a deadline for it, and those two sections do not name it [5][6].

Where it is kept

We found no source that says where a signed LIC 627C is kept. CDSS's list of records an RCFE keeps, LIC 311F, names LIC 627C only in its form index on page 3. Its "Residents Records" list (section I) does not name it [3]. The footer of the form reads "(CONFIDENTIAL)" [1]. Title 22 § 87506(c) says all information and records obtained from or regarding residents "shall be confidential" [5].

How long to keep it. Title 22 § 87506(e) sets "a minimum of three (3) years following termination of service to the resident" for original resident records, and the list of what a resident's record contains in § 87506(b) does not name this form [5]. We found no retention period for LIC 627C itself.

What the record must show

The consent text on the form reads [1]:

  • "I hereby give consent to" the facility "to provide all emergency medical or dental care prescribed by a duly licensed physician (M.D.) osteopath (D.O.) or dentist (D.D.S.)" for the named person
  • the care "may be given under whatever conditions are necessary to preserve the life, limb or well being of the individual named above"

A filled-in form shows [1]:

  • the facility name and the person's name
  • the medication allergies
  • the date, and the signature of the client, authorized representative or conservator, with the title circled
  • a home address, a home phone and a work phone

Questions

Do RCFEs use LIC 627C?

CDSS lists "LIC 627C - Consent For Emergency Medical Treatment" in the form index of LIC 311F, its (4/05) records list for residential care facilities for the elderly [3]. A CDSS forms-request sheet for RCFEs (LIC 183B, 10/03) also lists it [4]. The form's own title says "Adult And Elderly Residential Facilities" [1]. Title 22 §§ 87506 and 87507, on resident records and admission agreements, do not name the form [5][6].

Is LIC 627 the same as LIC 627C?

No. CDSS lists LIC 627 (9/08) as the consent for child care centers or family child care homes. It lists LIC 627B (9/08) as the consent for children's residential facilities [2]. LIC 627C (4/00) is the one titled for adult and elderly residential facilities [2].

Is there a Spanish version?

CDSS lists LIC 627C (4/00) on its Spanish forms page [7]. The English form's footer reads "ENG/SP" [1].

How Sevana Care keeps this record

Is the emergency treatment consent signed and filed? Each resident's documents have a place for the emergency medical treatment consent, the LIC 627C. Photograph or upload the signed copy, and the place flips from Missing to On file. We don't write the consent. Open a resident's documents in the sample home to see the places.

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 613C-2: The personal rights a resident signs at admission
  • LIC 601: The form with a resident's contacts, doctor, hospital and emergency details

Sources

  1. CDSS, LIC 627C (4/00), Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities (PDF)
  2. CDSS, Forms and Publications (I-L)
  3. CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
  4. 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)
  5. California Code of Regulations, Title 22, § 87506, Resident Records (Westlaw)
  6. California Code of Regulations, Title 22, § 87507, Admission Agreements (Westlaw)
  7. CDSS, Spanish forms and publications