Form LIC 627A. Consent To A Medical Examination

The LIC 627A form, titled "Consent to a Medical Examination," is an essential document governed by the California Department of Social Services, Community Care Licensing. This form serves a crucial role in ensuring the health and safety of individuals in child care centers or family child care homes.

The main purpose of the LIC 627A form is to obtain consent from individuals or their legal representatives for a medical examination. It is typically used in child care settings to ensure that the individuals under care are physically fit and do not pose any health risks to themselves or others. The form establishes a legally binding agreement between the child care provider and the individual or legal representative regarding the medical examination process.

The LIC 627A form consists of several important fields that must be completed accurately. These fields include:

1. Individual's Information: The full name, date of birth, gender, and contact details of the individual who will undergo the medical examination.

2. Legal Representative's Information (if applicable): In cases where the individual is unable to provide informed consent due to age or incapacity, the name and contact details of their legal representative should be provided.

3. Provider's information: The name, address, and contact details of the child care center or family child care home conducting the medical examination.

4. Consent Authorization: The individual or legal representative's signature, indicating their understanding and agreement to the medical examination.

When filling out the form, it is crucial to ensure that all required information is accurately provided. The individual or their legal representative must sign the form to grant consent for the medical examination. Additionally, any supporting documents related to the individual's medical history, such as previous medical records or reports, may need to be attached to the LIC 627A form to assist the examining healthcare professional.

Examples of application scenarios where the LIC 627A form would be necessary include situations where individuals are entering child care facilities or family child care homes. The form ensures that every individual undergoes a medical examination to assess their overall health and confirm that they are physically fit to participate in child care activities.

While the LIC 627A form is specific to California's Community Care Licensing, there may be related or alternative forms used in different jurisdictions or settings. These forms may vary in title and content but generally serve a similar purpose of obtaining consent for a medical examination.

Once completed, the LIC 627A form should be securely stored by the child care facility or family child care home. It is important to maintain confidentiality and ensure easy accessibility for reference or in case of regulatory inspections. The form may be submitted to the licensing agency during compliance inspections or requested by authorities to verify compliance with medical examination requirements.

In conclusion, the LIC 627A form plays a vital role in securing consent for a medical examination in California child care centers and family child care homes. By accurately completing this form, child care providers can prioritize the health and well-being of individuals under their care, ensuring a safe environment for all.