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 26 - 50 of 209 results

Form Number Form Name Associated Manual(s)
HC 7-A Sample Disclosure Regarding Ambulance Replenishing Mental Health Law Manual, Hospital Compliance Manual
HS 10 Sample Cover Letter for Hospital’s CMS-2567 Response California Hospital Survey Manual
8-5 Sample Arbitration Clause Consent Manual
10-B Safe Surrender Site Sign Mental Health Law Manual, Hospital Compliance Manual
PR 16-3 Response to Subpoena Duces Tecum California Health Information Privacy Manual
PR 15-5 Response to Request to Amend Protected Health Information California Health Information Privacy Manual
PR 15-11 Response to Request for Special Restriction on Use or Disclosure of Protected Health Information California Health Information Privacy Manual
PR 17-2 Response to Request for Confidential Information California Health Information Privacy Manual
PR 15-9 Response to Request for an Accounting of Disclosures California Health Information Privacy Manual
16-2 Request to Withhold Public Release of Information Consent Manual, California Health Information Privacy Manual
PR 15-4 Request to Amend Protected Health Information California Health Information Privacy Manual
5-4 Request Regarding Resuscitative Measures Consent Manual
12-1 Request for Voluntary Admission and Authorization for Treatment Consent Manual
PR 15-10 Request for Special Restriction on Use or Disclosure of Protected Health Information California Health Information Privacy Manual
12-9 Request for Release from Involuntary Treatment Consent Manual
24-5 Request for Presence of Observer During Childbirth/Medical Procedure Consent Manual, California Health Information Privacy Manual
PR 15-8 Request for an Accounting of Disclosures California Health Information Privacy Manual
PR 15-13 Request for Alternative Means of Communication California Health Information Privacy Manual
PR 16-6 Request for Access to Hospital Records or Other Documents California Health Information Privacy Manual
21-2 Report to Attorney Consent Manual
19-3 Report of Injury or Condition Resulting From Neglect or Abuse (To a Patient Received From a Licensed Health Facility) Consent Manual
25-A Report of Hospital Death Associated With Restraint or Seclusion Consent Manual
24-1 Release of Side Rails Consent Manual
10-3 Release of a Child Under 8 Years of Age Consent Manual
4-5 Release from Responsibility for Treatment of Miscarriage or Partial Abortion Consent Manual