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Form 4835 for Burbank California: What You Should Know
Form 4868 — CA CARE LEADS — CERTIFICATE OF SERVICE (2) A caretaker of the patient who is a beneficiary under Section 1829 or 1860.5 of the California Welfare and Institutions Code, or a disabled adult who is a beneficiary under Section 1718 or 1728.3 of the California Civil Code, shall deliver or mail to the applicant the following: (A) Two (2) copies of the form in duplicate (the original and one copy) of which one copy must be forwarded to the care provider and one copy to the patient's legal guardian. An affidavit of completion of this form shall be provided. The affidavit shall, in addition to stating the names and addresses of the caretaker(s) and the person(s) to whom the form may be delivered or mailed, identify the patient(s), the purpose(s) and, if required, the date(s), time and location(s) of delivery, the form number, and the date and location of the signature of all persons to whom the form may be delivered or mailed. Any person submitting an affidavit on an application or renewal form shall be allowed for use of the form if they file the affidavit with the application form, in writing, within five (5) business days immediately following the receipt of the application or renewal form. (B) Copies of all original records. Copies of medical records regarding an applicant or a patient for whom the applicant is the caretaker(s). (D) A statement that the caretaker(s) of the patient is entitled to obtain copies of medical records regarding an applicant or a patient. (E) An affidavit of completion of the forms. Possession By Applicants In California (Form 4868) (1) Form 4868 cannot be mailed to the caretaker of the patient. (A) If you need to take possession of or obtain possession of a patient's farm property but do not know their name or address, you must serve the caretaker(s) of the patient, or, if known, the personal representative of their estate. To serve the personal representative, complete this form and mail it to the personal representative.
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