Lic 604a 2026

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  1. Click ‘Get Form’ to open the lic 604a in the editor.
  2. Begin by filling out the 'Facility Information' section. Enter the name, type, address, city, state, zip code, and telephone number of your facility.
  3. In the 'Basic Services' section, specify the name of the client/resident and their birthdate. Indicate whether they will be in a single or double room and list any special dietary needs.
  4. Complete the 'Optional Services' section by detailing any additional services offered along with their rates and payment schedules.
  5. Fill in the total monthly rate for both basic and optional services at the end of the form.
  6. Review all sections for accuracy before signing. Ensure that both you and the client/resident or authorized representative sign and date where indicated.

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