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)
WVP Appendix A Cal/OSHA Healthcare Workplace Violence Prevention Regulation Healthcare Workplace Violence Prevention
WVP Appendix B Cal/OSHA Injury and Illness Prevention Program Regulation Healthcare Workplace Violence Prevention
HS 1 California Department of Public Health Organization Chart California Hospital Survey Manual
Appendix D California Hospital Licensing Laws on Emergency Services and Care EMTALA Manual
DP Appendix A California’s Discharge Planning Law The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
2-2 Caregiver’s Authorization Affidavit Consent Manual
Appendix U CDPH All-Facility Letter 12-17 (May 17, 2012) EMTALA Manual
12-4 Certificate of Admitting Physician Consent Manual
Appendix P CHA Transfer Forms and Model Signage EMTALA Manual
PR 16-7 Civil Subpoena: Duces Tecum California Health Information Privacy Manual
Appendix V CMS Letter Regarding Transfer of Patients to Crisis Stabilization Units EMTALA Manual
HC 11-B CMS State Medicaid Director Letter Mental Health Law Manual, Hospital Compliance Manual
Appendix Z CMS Survey and Certification Memoranda 06-21 and 07-20: Detaining EMS Personnel and Equipment (July 13, 2006 and April 27, 2007) EMTALA Manual
Appendix AA CMS Survey and Certification Memoranda 15-10 and 15-24: EMTALA and Ebola (Nov. 21, 2014 and Feb. 13, 2015) EMTALA Manual
Appendix Q CMS Survey and Certification Memorandum 08-08: Requirements for Off-Campus Emergency Departments (Jan. 11, 2008) EMTALA Manual
Appendix R CMS Survey and Certification Memorandum 09-52: EMTALA Options in a Disaster (Aug. 14, 2009) EMTALA Manual
Appendix Y CMS Survey and Certification Memorandum 13-38: Critical Access Hospital Emergency Services and Telemedicine (June 7, 2013) EMTALA Manual
Appendix X CMS Survey and Certification Memorandum 14-06: EMTALA Requirements & Conflicting Payor Requirements or Collection Practices (Dec. 13, 2013) EMTALA Manual
FAP 2 Comparison of California and IRS Requirements for Community Health Needs Assessments and Plans Mental Health Law Manual, Hospital Compliance Manual
FAP 3 Comparison of California and IRS Requirements Regarding Financial Assistance Policies Mental Health Law Manual, Hospital Compliance Manual
8-1 Conditions of Admission Consent Manual
HC 1-B Conflict of Interest Certification Form Mental Health Law Manual, Hospital Compliance Manual
9-11 Consent for Participation in Patient Outing Consent Manual
2-B Consent Requirements for Medical Treatment of Minors
4-8 Consent to Donation of Sperm, Ova or Embryos Consent Manual