LIC 601: Identification and Emergency Information

What Is LIC 601?

LIC 601, Identification and Emergency Information, is used to keep essential information about each resident readily available to the person in charge of the facility.

The form includes key information such as the resident's personal details, responsible person, financial or legal representative, emergency contacts, physician, dentist, emergency hospitalization plan, and other required information. The form also states that the information must be kept current and protected from unauthorized access.

For RCFE owners, the goal is simple: make sure the right information is available when it is needed most.

Official LIC 601 Form

The current LIC 601 is published by the California Department of Social Services (CDSS). RCFE Connect links directly to the official source rather than hosting a copy, so you can access the form from CDSS.

[Open LIC 601 on CDSS]

Who Completes LIC 601 and When?

The facility is responsible for maintaining LIC 601 for each person admitted to the facility.

The form should be completed as part of the resident's admission process and kept current throughout the resident's stay. Information should be updated whenever relevant details change, such as contact information, responsible parties, physicians, or emergency arrangements.

What Information Is Included on LIC 601?

LIC 601 covers several types of resident and emergency information, including:

• Resident's name, date of birth, age, and sex

• Responsible person or placement agency

• Nearest relative

• Date of admission and address prior to admission

• Persons responsible for financial affairs, payment for care, or legal guardianship

• Emergency contacts

• Physician, mental health provider, and dentist information

• Emergency hospitalization plan

• Medical and dental plan information

• Ambulatory status

• Religious preference and religious advisor, if applicable

• Additional comments

• Required signatures and date

How to Complete LIC 601

1. Gather the resident's basic information

Enter the resident's identifying information, including their full name, date of birth, age, and other information requested on the form.

2. Record the responsible person and emergency contacts

Enter the responsible person or placement agency, nearest relative when applicable, and the people who should be contacted in an emergency.

Make sure phone numbers and addresses are accurate and usable.

3. Add healthcare provider information

Record the resident's physician and, when applicable, mental health provider and dentist.

4. Complete the emergency hospitalization information

Document the hospital designated for emergency hospitalization and the applicable medical or dental plan information.

5. Complete the remaining required information

Review the sections covering ambulatory status, religious preference when applicable, and any additional comments.

6. Review, sign, and keep the form current

Make sure the required signatures and date are completed. The facility should maintain the form in the resident's record and update the information whenever it changes.

Common LIC 601 Mistakes to Avoid

A completed form is only useful if the information is accurate and current.

Watch for:

• Outdated emergency contact information — A family member may have changed their phone number, address, or availability.

• Incomplete healthcare provider information — Physician, dentist, or other applicable provider information may be missing.

• Missing signatures or dates — Review the signature section before filing the form.

• Outdated emergency arrangements — Hospital or insurance information may change during a resident's stay.

• Failing to update the form — LIC 601 states that the information must be kept current.

LIC 601 Quick Check

Before filing or reviewing a LIC 601, check that:

☐ Resident information is complete
☐ Responsible person information is current
☐ Emergency contacts have current contact information
☐ Physician and other applicable healthcare provider information is recorded
☐ Emergency hospitalization information is complete
☐ Medical and dental plan information is current, when applicable
☐ Required signatures and date are completed
☐ The information is updated whenever relevant details change

Frequently Asked Questions

When does LIC 601 need to be completed?

LIC 601 should be maintained for every resident admitted to the facility. The form should be completed as part of the admission process and kept current throughout the resident's stay.

Review the form whenever information changes, such as the resident's responsible person, emergency contacts, physician, dentist, medical plan, or emergency hospitalization information.

Who signs LIC 601?

LIC 601 includes two signature lines: one for the resident and one for the person completing the form. The person completing the form must also provide their title and the date.

Does LIC 601 need to be updated?

Yes. The form itself states that the information must be kept current. Update the form when relevant resident, contact, healthcare provider, or emergency information changes.

Where should LIC 601 be kept?

The form states that the information should be maintained so that it is readily available to the person in charge, while not being accessible to unauthorized persons.

More California RCFE LIC Forms

LIC 601 is one of many forms used in California's residential care system.

RCFE Connect is building a practical library to help facility owners understand what different LIC forms are for, when they are used, and what to check when completing them.

More LIC form guides coming soon.