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 1-A Workplace Violence Incident Case Number Assignment Form Healthcare Workplace Violence Prevention
6-3 Warrantless Medical Search Request by Peace Officer (When Subject Refuses to Consent) Consent Manual
HS 4 Unusual Occurrences Reporting Requirement California Hospital Survey Manual
Appendix 9-B Types of MCPs and MHPs Consent Manual
4-1 Transfusion Information Form Consent Manual
9-2 Transfer Summary (Transfer From Acute Hospital to SNF) Consent Manual
HS 8 Timeline for 90-Day Termination Track California Hospital Survey Manual
HS 9 Timeline for 23-Day Termination Track California Hospital Survey Manual
PR 16-4 Time Extension for Compliance with Subpoena California Health Information Privacy Manual
PR 15-12 Termination of Special Restriction California Health Information Privacy Manual
9-10 Temporary Absence Release Consent Manual
HC 9-B Summary of Significant Factors Determining the Permissibility of Participation in Partnership Mental Health Law Manual, Hospital Compliance Manual
12-A Summary of Lanterman-Petris-Short Act’s Provisions for Involuntary Evaluation and Treatment and Right of Review Consent Manual
12-2 Statement of Professional Person Responsible for Minor’s Admission Consent Manual
PR 15-7 Statement of Disagreement: Request to Include Amendment Request and Denial with Future Disclosures California Health Information Privacy Manual
HS 5 State-2567: Statement of Deficiencies and Plan of Correction California Hospital Survey Manual
HC 11-C State Medicaid Excluded Provider List Mental Health Law Manual, Hospital Compliance Manual
Appendix H Special Advisory Bulletin EMTALA Manual
2-1 Self-Sufficient Minor Information Consent Manual
2-C Selection of Health Care Surrogates With the Assistance of Health Care Professionals – Sample Policy Consent Manual
Appendix T Sample Transfer Checklist and Script for Accepting Emergency Patients EMTALA Manual
Appendix S Sample Transfer Agreement EMTALA Manual
Appendix L Sample Survey Tools for Patient Transfers and Medical Screening Examinations EMTALA Manual
DP 1-B Sample Questionnaires to Determine Whether a Patient is Homeless as Defined in State Law The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
DP Appendix C Sample Language for Homeless Patient Discharge Planning Policy The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients