Transcription of IDENTIFICATION AND EMERGENCY INFORMATION
1 STATE OF CALIFORNIAHEALTH AND HUMAN services AGENCYCALIFORNIA department OF social SERVICESCOMMUNITY CARE LICENSING DIVISIONIDENTIFICATION ANDEMERGENCY INFORMATIONThis INFORMATION is required under the H & S Code and the regulationsof the department to be maintained on every person admitted to acommunity care facility, to be readily available to the person in charge,but not accessible to unauthorized persons. All INFORMATION must bekept current. See other side for additional INFORMATION required forresidential facilities for ALL FACILITIES [EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700]PERSON(S) RESPONSIBLE FOR FINANCIAL AFFAIRS, PAYMENT FOR CARE, LEGAL GUARDIAN, IF ANYOTHER PERSONS TO BE NOTIFIED IN EMERGENCYEMERGENCY HOSPITALIZATION PLANOTHER REQUIRED INFORMATION1. NAME OF CLIENT OR CHILD2. RESPONSIBLE PERSON OR PLACEMENT AGENCY3. NAME OF NEAREST RELATIVE (OPTIONAL)4. DATE ADMITTED TO FACILITY5. DATE LEFT6.
2 REASONS FOR LEAVING FACILITYa. PHYSICIANb. MENTAL HEALTH PROVIDER, IF ANYc. DENTISTd. RELATIVE(S)e. FRIEND(S)a. AMBULATORY STATUSb. RELIGIOUS PREFERENCE11. COMMENTSSIGNATURE OF RESIDENTSIGNATURE OF PERSON COMPLETING FORMTITLEDATENAME AND ADDRESS OF CLERGYMAN OR RELIGIOUS ADVISOR, IF ANYTELEPHONE( )NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCYADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCYMEDICAL PLAN IDENTIFICATION NUMBERDENTAL PLAN NUMBER (IF ANY)MEDICAL PLANNAME OF DENTAL PLAN (IF ANY) PRIOR TO ADMISSIONFORWARDING ADDRESSADDRESSADDRESSTELEPHONE( )TELEPHONE( )( )( )( )( )( )( )( )( ) social SECURITY NUMBER (OPTIONAL)DATE OF BIRTHAGESEXNAMEADDRESSTELEPHONENAMEADDRE SSTELEPHONELIC 601 (8/08) PersonalPage 1 of 2 NAME AND RELATIONSHIPADDRESSTELEPHONETELEPHONE ACCESSSPECIFY, IF ANYFAMILY RESIDENCE VISITATION RESTRICTIONSALL PERSONS AUTHORIZED TO REMOVE CHILD FROM HOMEVISITATION RESTRICTIONS (BY COURT ORDER OR AUTHORIZED REPRESENTATIVE)PERSON(S) NOT AUTHORIZED TO VISIT CHILDPERSON(S) NOT AUTHORIZED TO VISIT CHILDNAMERELATIONSHIPNAMERELATIONSHIPPER SON(S)
3 WITH WHOM CHILD HAS BEEN LIVING (IF KNOWN)B. RESIDENTIAL FACILITIES FOR CHILDREN(Additional INFORMATION is required by regulation for residential facilities for children.)1. NAME OF COMMENTS2. NAME AND ADDRESS OF PERSON TO CONTACT, IF AUTHORIZED REPRESENTATIVE IS NOT AVAILABLE3. NAME AND ADDRESS OF PARENT(S)/PARENT S DOMESTIC PARTNER, IF KNOWN4. CHILD S COURT STATUS (ATTACH CUSTODY ORDERS AND AGREEMENTS WITH PARENT(S), OR PERSON(S) HAVING LEGAL CUSTODY. NOTE: OPTIONAL FOR SMALL FAMILY AND FOSTER FAMILY HOMES)SPECIFY RELATIONSHIPTELEPHONE NUMBER( )TELEPHONE NUMBER( )( )( )( )NAMERELATIONSHIPSPECIFY CONDITIONSIF NO, SPECIFY RESTRICTIONSMAKE AND RECEIVE CONFIDENTIAL CALLS YES NO (BY COURT ORDER)LIC 601 (8/08) PersonalPage 2 of 2
