Lic 624a 2026

1. Click ‘Get Form’ to open the lic 624a in the editor.
2. Begin by entering the 'Name of Facility' and 'Facility File Number' at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Fill in the 'Address', 'City, State, ZIP', and 'Telephone Number' fields. This helps in maintaining clear communication with relevant agencies.
4. Provide the 'Client’s Name', 'D.O.B.', and 'Date of Admission'. These details are essential for record-keeping and must be filled out correctly.
5. Document the 'Place of Death', along with the 'Date and Time of Death'. This information is vital for reporting purposes.
6. In the section regarding immediate cause of death, describe it thoroughly. If a coroner's report exists, remember to upload it within 30 days.
7. Detail any conditions that contributed to death in the next field. This provides context for your report.
8. Explain what immediate actions were taken following the death, including names of persons contacted.
9. Indicate whether medical treatment was necessary by selecting ‘Yes’ or ‘No’. If yes, specify the nature of treatment required.
10. Complete sections for names and titles of individuals submitting and reviewing/approving the report, ensuring all parties are documented.
11. Finally, list all agencies or individuals notified about the incident, including their contact numbers for verification purposes.

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