Lic 9020-2026

1. Click ‘Get Form’ to open the lic 9020 in the editor.
2. Begin by entering the Facility Name, which designates the specific facility under application.
3. Next, input the Facility Number assigned to your establishment.
4. Enter the Licensee Name, identifying the individual or entity responsible for operating the facility.
5. Record the Date/Update to indicate when this information is being documented or revised.
6. If applicable, provide a Room Identifier for Residential Care clients to specify their room number.
7. Fill in the Client/Resident Name with their legal name as required.
8. Select the appropriate Ambulatory Status by checking one of the boxes that best describes the resident's mobility.
9. Input details of the attending Physician including their name, address, and phone number.
10. Finally, enter information for the Responsible Person who oversees or assists with the resident's care.

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