Get Lic 604 2020-2025

Filling out the Lic 604 form is an essential step for residential facilities to establish a clear admission agreement with clients or residents. This guide will provide you with a step-by-step approach to effectively complete the form online, ensuring that all necessary information is accurately captured.

Follow the steps to successfully complete the Lic 604 form.

1. Press the ‘Get Form’ button to retrieve the Lic 604 form and open it in the online editor.
2. Begin by filling out the facility information section. Include the name, type, address, city, state, zip code, and telephone number of your residential care facility. Ensure all details are accurate and up-to-date.
3. In the basic services section, provide the name of the client or resident along with their social security number (if applicable) and birthdate. Then, outline the basic general services that will be provided, such as lodging options, food services, and other essential services.
4. Specify the monthly rate for basic services in the respective section. Indicate whether the payments are made in advance or in arrears, and reference any government-funded rates if applicable.
5. Detail any optional services your facility offers, including service intervals, specific services provided, rates, and the pay schedule. Calculate the total monthly rate for optional services and note if these are paid in advance or in arrears.
6. Summarize the total monthly rate for both basic and optional services in the designated area.
7. Complete the eviction procedures section, indicating the reasons for possible eviction and the notice periods required.
8. Outline the facility's visiting policy, ensuring it is clear and comprehensive.
9. Fill out the discharge/removal policies, notice of rate changes, and refund policy sections. Make sure to provide details that reflect the operational policies of your facility.
10. Finally, include signatures for the client/resident or their authorized representative, the licensee/administrator, and the date signed. Ensure that the admission agreement is completed and signed in duplicate, keeping one copy for your records and providing one to the resident.
11. Upon completing the form, make sure to save your changes. You may then download the document, print it, or share it as needed.

Don't wait to complete the necessary documentation; fill out your Lic 604 form online today!