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ITIES FOR THE ELDERLY (RCFE) I. FACILITY INFORMATION (To be completed by the licensee/designee) 1. NAME OF FACILITY 3. ADDRESS 2. TELEPHONE ( ) ZIP CODE CITY 4. LICENSEE’S NAME 5. TELEPHONE ( ) 6. FACILITY LICENSE NUMBER II. RESIDENT/PATIENT INFORMATION (To be completed by the resident/resident's responsible person) 2. BIRTH DATE 3. AGE 1. NAME III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (To be completed by resident/resident's legal representative) I hereby authorize release o.

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