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 76 - 100 of 209 results

Form Number Form Name Associated Manual(s)
19-4 Employee Acknowledgment of Elder and Dependent Adult Abuse Reporting Obligations Consent Manual
4-4 Employee or Medical Staff Member Statement Consent Manual
Appendix B EMTALA and Emergency-Related Federal Regulations EMTALA Manual
Appendix I EMTALA Enforcement Chart EMTALA Manual
Appendix C EMTALA Interpretive Guidelines (Part II: Responsibilities of Medicare Participating Hospitals in Emergency Cases) EMTALA Manual
Appendix W EMTALA Physician Review Worksheet EMTALA Manual
Appendix A EMTALA Statute EMTALA Manual
WVP 1-D Environmental Risk Factor Worksheet Healthcare Workplace Violence Prevention
7-1 Experimental Subject’s Bill of Rights Consent Manual
HS 13 FAQs on Writing Hospital Policies and Procedures California Hospital Survey Manual
PR 12-A Federal and State Breach Notification Laws for California California Health Information Privacy Manual
HS 15 Federal vs. State Immediate Jeopardy Definition and Implementation Comparison California Hospital Survey Manual
HS 7 Form CMS-2567: Statement of Deficiencies and Plan of Correction California Hospital Survey Manual
2-D Health Care Decisions for Unrepresented Patients Consent Manual
PR 12-B HIPAA Breach Decision Tool and Risk Assessment Documentation Form California Health Information Privacy Manual
PR 10-A HIPAA Security Standards Matrix California Health Information Privacy Manual
PR 1-B HIPAA Standard Regarding De-Identification and Re-Identification of PHI California Health Information Privacy Manual
PR 1-C HIPAA Standard Regarding Limited Data Set California Health Information Privacy Manual
DP 1-A Homeless Patient Discharge Planning Worksheet The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
DP 1-D Homeless Shelter Information Sheet The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
Appendix J Hospital Records Subject to EMTALA Enforcement Survey EMTALA Manual
21-1 Incident Report Consent Manual
1-2 Informed Consent to Surgery or Special Procedure Consent Manual
HS 14 Instructions for Calculating an Administrative Penalty California Hospital Survey Manual
Appendix K Investigative Procedures for EMTALA Surveyors EMTALA Manual