Physician'S Report For Community Care Facilities
Download a blank fillable Physician'S Report For Community Care Facilities in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Physician'S Report For Community Care Facilities with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
PHYSICIAN’S REPORT FOR COMMUNITY CARE FACILITIES
For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF).
NOTE TO PHYSICIAN:
The person specified below is a resident/client of or an applicant for admission to a licensed Community Care Facility. These
types of facilities are currently responsible for providing the level of care and supervision, primarily nonmedical care, necessary
to meet the needs of the individual residents/clients.
THESE FACILITIES DO NOT PROVIDE PROFESSIONAL NURSING CARE.
The information that you complete on this person is required by law to assist in determining whether he/she is appropriate for
admission to or continued care in a facility.
FACILITY INFORMATION (To be completed by the licensee/designee)
NAME OF FACILITY:
TELEPHONE:
`
ADDRESS:
NUMBER
STREET
CITY
LICENSEE’S NAME:
TELEPHONE:
FACILITY LICENSE NUMBER:
RESIDENT/CLIENT INFORMATION (To be completed by the resident/authorized representative/licensee)
NAME:
TELEPHONE:
ADDRESS:
NUMBER
STREET
CITY
SOCIAL SECURITY NUMBER:
NEXT OF KIN:
PERSON RESPONSIBLE FOR THIS PERSON’S FINANCES:
PATIENT’S DIAGNOSIS (To be completed by the physician)
PRIMARY DIAGNOSIS:
SECONDARY DIAGNOSIS:
LENGTH OF TIME UNDER YOUR CARE:
AGE:
HEIGHT:
SEX:
WEIGHT:
IN YOUR OPINION DOES THIS PERSON REQUIRE SKILLED NURSING CARE?
■ ■
■ ■
YES
NO
TUBERCULOSIS EXAMINATION RESULTS:
DATE OF LAST TB TEST:
■ ■
■ ■
■ ■
ACTIVE
INACTIVE
NONE
TYPE OF TB TEST USED:
TREATMENT/MEDICATION:
■ ■
■ ■
YES
NO
If YES, list below:
OTHER CONTAGIOUS/INFECTIOUS DISEASES:
TREATMENT/MEDICATION:
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
A)
If YES, list below:
B)
If YES, list below:
TREATMENT/MEDICATION:
ALLERGIES
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
C)
If YES, list below:
D)
If YES, list below:
PAGE 1 OF 3
LIC 602 (7/11)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal