License Number Facility/Home Address (Street Number and Name) PLEASE MAIL TO City Licensing Consultant (Name, Address, Phone) Licensing and Regulatory Affairs Child Care Licensing PO Box 30664 Lansing, MI 48909 State Zip Code License Application Type Child Care (Less Than 24-Hour Care) PATIENT INFORMATION (To be Completed by Patient) (Please Print or Type) Name (Last, First, Middle, Jr., II, etc.) Date of Birth Telephone Number Address (Street Number and Name) City State Zip C.
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the MI BCAL-3704-CC online
The MI BCAL-3704-CC is a medical clearance request form essential for child care licensing in Michigan. This guide provides a step-by-step approach to assist users in accurately completing the form online.
Follow the steps to fill out the MI BCAL-3704-CC online accurately.
- Click ‘Get Form’ button to access the MI BCAL-3704-CC form and open it in your preferred online editor.
- In the 'Applicant/Licensee Information' section, provide the facility or home name, license number, and the full address, including the city, state, and zip code.
- Next, fill in the 'Licensing Consultant' information by including their name, complete address, and phone number.
- In the 'Patient Information' section, enter the patient's name, date of birth, telephone number, and their complete address.
- For the 'Release of Information' section, specify the date and obtain the patient's signature, as well as the physician's name printed clearly.
- Proceed to the 'Medical Information' section to provide details regarding the patient's physical and mental health condition. Answer the questions regarding TB testing and describe the patient's condition. Use the comments section as needed for additional explanations.
- Finally, ensure the physician signs and dates the form, providing their address and telephone number to complete the submission.
- Once all sections are thoroughly filled, you may save changes, download, print, or share the completed form as needed.
Complete your MI BCAL-3704-CC form online today for a smooth licensing process.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
BCAL-3704-CC (3-19) MS Word. MEDICAL CLEARANCE REQUEST – CHILD CARE LICENSING. Michigan...
BCAL-3704-CC (2-16) MS Word. MEDICAL CLEARANCE REQUEST – CHILD CARE LICENSING. Michigan...
9 Feb 2015 — H I G HT R U EW A V E F O R MI N F O R M A T I O N AUTO ZERO=MT-B ... this...
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.
This form is available in several versions. Select the version you need from the drop-down list below.