LIC 627C — Consent for Emergency Medical Treatment — Adult and Elderly Residential Facilities
LIC 627C is the advance consent for emergency medical treatment used in adult and elderly residential facilities. It lets staff obtain emergency care when the resident cannot consent in the moment.
Official PDF
The current LIC 627C is published by the California Department of Social Services. We link to the live source rather than hosting a copy, so you always get the latest revision.
Open LIC 627C on cdss.ca.govWho completes it and when
The resident or their legal representative signs; the facility retains it.
Signed at admission.
How to complete LIC 627C
- 1Present the consent at admission, alongside the admission agreement and personal rights.
- 2Confirm the signer has legal authority if the resident cannot sign for themselves.
- 3Record the physician and preferred hospital where the form asks for them.
- 4File the signed form where staff can retrieve it in seconds during an emergency, not buried in the back of a binder.
- 5Refresh it when the responsible party or physician changes.
Mistakes evaluators flag
- Signed by a family member with no documented legal authority.
- Kept in an archive box instead of the active emergency packet.
Questions about LIC 627C
Does LIC 627C replace an advance directive?
No. It authorizes emergency treatment when the resident cannot consent. Advance directives and POLST forms are separate documents kept with the resident record.
Fill this form from data you already have
- Resident, staff, and facility details populate the form fields automatically.
- Track which forms are on file, which are missing, and which are about to expire.
- Incident reports draft the LIC 624 narrative and finalize an immutable PDF.
Related admission forms
RCFE OS is not affiliated with the California Department of Social Services. This guide is operational information for licensees, not legal advice. Always follow the current form instructions and guidance from your licensing analyst.