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)
HC 1-A Acknowledgment of Receipt of Hospital Compliance Plan Mental Health Law Manual, Hospital Compliance Manual
10-2 Acknowledgment of Release of a Minor Consent Manual
PR 1-A Acronyms California Health Information Privacy Manual
3-1 Advance Health Care Directive Consent Manual
12-7 Advisement of Rights – Involuntary Patient Consent Manual
PR 16-5 Affidavit of Custodian of Medical Records to Accompany Copies of Records California Health Information Privacy Manual
13-3 Aftercare Plan Consent Manual
14-1 Agreement for Facsimile Transmission of Psychiatric Records Consent Manual
Appendix M An Explanation of the Scope of RN Practice Including Standardized Procedures EMTALA Manual
12-5 Application of Involuntary Admission – Inebriates Consent Manual
19-A Assault and Abuse Reporting Requirements Consent Manual
19-1 Assault or Battery Against Hospital Personnel Healthcare Workplace Violence Prevention
8-3 Assignment of Proceeds of Claim Consent Manual
11-2 Authorization for Anatomical Gift Consent Manual
4-3 Authorization for and Consent to Hysterectomy Consent Manual
11-1 Authorization for Autopsy Consent Manual
PR 16-11 Authorization for Disclosure of health Information Pursuant to Evidence Code Section 1158 California Health Information Privacy Manual
10-1 Authorization for Release of a Minor Consent Manual
2-3 Authorization for Third Party to Consent for Treatment of Minor Lacking Capacity to Consent Consent Manual
16-1 Authorization for Use or Disclosure of Health Information Consent Manual, California Health Information Privacy Manual
10-A Baby Stalking Sign Mental Health Law Manual, Consent Manual, Hospital Compliance Manual
4-B Be Informed (Breast Cancer) Mental Health Law Manual, Consent Manual, Hospital Compliance Manual
4-C Be Informed (Prostate Cancer) Consent Manual
6-1 Blood Test Request by Peace Officer Consent Manual, California Health Information Privacy Manual
PR 11-B Business Associate Addendum California Health Information Privacy Manual