Forms and Appendices

Hospitals that are members of the California Hospital Association may use these model forms, appendices, signs and handouts as templates in developing their own forms, signs and handouts.

CHA forms are updated periodically. The current version of CHA forms are downloadable from this page, and may or may not match the forms found in CHA’s printed manuals. The date on which each form was last updated appears in the lower right corner of each form.

Hospitals that are members of the California Hospital Association may use these model forms, appendices, signs and handouts as templates in developing their own forms, signs and handouts.

This content is restricted to members.

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Showing 1 - 25 of 209 results

Form Number Form Name Associated Manual(s)
WVP Appendix D Definition of “Dangerous Weapon” for Law Enforcement Reporting Requirement Healthcare Workplace Violence Prevention
WVP Appendix B Cal/OSHA Injury and Illness Prevention Program Regulation Healthcare Workplace Violence Prevention
WVP Appendix A Cal/OSHA Healthcare Workplace Violence Prevention Regulation Healthcare Workplace Violence Prevention
WVP 1-D Environmental Risk Factor Worksheet Healthcare Workplace Violence Prevention
WVP 1-C Documentation of Workplace Violence Prevention Training Healthcare Workplace Violence Prevention
WVP 1-B Documentation of Investigation of Workplace Violence Incident Healthcare Workplace Violence Prevention
WVP 1-A Workplace Violence Incident Case Number Assignment Form Healthcare Workplace Violence Prevention
PR 3-A Disclosures That Must Be Accounted For California Health Information Privacy Manual
PR 18-B Notice to Patient: Confidentiality of Substance Use Disorder Patient Records California Health Information Privacy Manual
PR 18-A Order for Production of Substance Use Disorder Records California Health Information Privacy Manual
PR 17-2 Response to Request for Confidential Information California Health Information Privacy Manual
PR 17-2 Order for Production of Mental Health Records California Health Information Privacy Manual
PR 16-9 Deposition Subpoena for Production of Business Records California Health Information Privacy Manual
PR 16-8 Deposition Subpoena for Personal Appearance and Production of Documents and Things California Health Information Privacy Manual
PR 16-7 Civil Subpoena: Duces Tecum California Health Information Privacy Manual
PR 16-6 Request for Access to Hospital Records or Other Documents California Health Information Privacy Manual
PR 16-6 Notification of Amendment to Protected Health Information California Health Information Privacy Manual
PR 16-5 Affidavit of Custodian of Medical Records to Accompany Copies of Records California Health Information Privacy Manual
PR 16-4 Time Extension for Compliance with Subpoena California Health Information Privacy Manual
PR 16-3 Response to Subpoena Duces Tecum California Health Information Privacy Manual
PR 16-11 Authorization for Disclosure of health Information Pursuant to Evidence Code Section 1158 California Health Information Privacy Manual
PR 16-10 Notice to Consumer or Employee and Objection California Health Information Privacy Manual
PR 15-9 Response to Request for an Accounting of Disclosures California Health Information Privacy Manual
PR 15-8 Request for an Accounting of Disclosures California Health Information Privacy Manual
PR 15-7 Statement of Disagreement: Request to Include Amendment Request and Denial with Future Disclosures California Health Information Privacy Manual