Get Quality Assurance Division Licensure Bureau - Dphhs Mt

Filling out the Quality Assurance Division Licensure Bureau form online can be straightforward when you have the right guidance. This user-friendly guide will walk you through each section of the form, ensuring you provide all necessary information accurately.

Follow the steps to complete your application seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the child's name in the designated field to ensure accurate identification. Then, fill in the child's birth date and current address.
3. Provide the mother's or legal guardian's information by entering their name, home number, address, cell number, work address, and work number in the specified fields.
4. Repeat the previous step for the father's or legal guardian's details to ensure that both guardians are listed.
5. List the emergency contact persons in the provided fields. Include their names and contact numbers to ensure they can be reached when necessary.
6. Indicate the physician or medical care source details and their contact number to facilitate medical assistance if needed.
7. Fill in the health insurance carrier and policy number for comprehensive medical coverage information.
8. Authorize individuals who are permitted to pick up the child by entering their names in the corresponding fields.
9. On the reverse side of the form, indicate consent for emergency medical care, administration of prescription and non-prescription medications, and special dietary needs by checking ‘Yes’ or ‘No’ boxes.
10. Provide any specific instructions for the child's transportation or special care needs during transit.
11. Complete the health history section by checking ‘Yes’ or ‘No’ for various health concerns. If applicable, provide explanations for each condition.
12. Finally, ensure to sign and date the form at the designated area to confirm your consent and provide a complete application.

Get started on completing the Quality Assurance Division Licensure Bureau form online today!