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 51 - 75 of 209 results

Form Number Form Name Associated Manual(s)
DP Appendix D Regional Vice President Geographical Distribution The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
10-5 Refusal to Permit Rho(D)-Immune Globulin Administration Consent Manual
5-1 Refusal to Permit Medical Treatment Consent Manual
10-6 Refusal to Permit Administration of an Approved Prophylactic Agent to the Eyes of Newborn Consent Manual
23-2 Refusal to Consent to Communicable Disease Testing/Refusal to Receive Results of Communicable Disease Testing Consent Manual
5-2 Refusal of Blood Products Consent Manual
HC 12-H Referrals: It’s Your Choice Mental Health Law Manual, Hospital Compliance Manual
PR 12-D Questionnaire and Confidentiality Agreement (Electronic PHI) California Health Information Privacy Manual
PR 12-C Questionnaire and Confidentiality Agreement California Health Information Privacy Manual
Appendix N Policies Recommended for EMTALA Compliance EMTALA Manual
5-B Physician Orders for Life-Sustaining Treatment (POLST) Consent Manual
9-4 Physician Certification Consent Manual
9-5 Physician Authorization for Transfer Consent Manual
12-11 Petition for Postcertification Treatment of Imminently Dangerous Person Consent Manual
Appendix 9-E Pertinent Legal Definitions of Emergency Psychiatric Conditions Consent Manual
Pertinent DHCS Plan Letters Consent Manual
24-2 Permit for Using Electrical Appliances Consent Manual
9-7 Patient Transfer Acknowledgment Consent Manual
1-A Patient Rights Mental Health Law Manual, Consent Manual, Hospital Compliance Manual
9-8 Patient Request for Transfer or Discharge Consent Manual
9-1 Patient Refusal of Transfer Consent Manual
9-6 Patient Refusal of Further Medical Treatment Consent Manual
PR 18-A Order for Production of Substance Use Disorder Records California Health Information Privacy Manual
PR 17-2 Order for Production of Mental Health Records California Health Information Privacy Manual
10-C Obstetrical Care Notice Mental Health Law Manual, Hospital Compliance Manual