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.

Showing 26 - 50 of 209 results

Form Number Form Name Associated Manual(s)
4-C Be Informed (Prostate Cancer) 2024 Consent Manual
5-1 Refusal to Permit Medical Treatment 2024 Consent Manual
5-2 Refusal of Blood Products 2024 Consent Manual
5-3 Leaving Hospital Against Medical Advice 2024 Consent Manual
5-4 Request Regarding Resuscitative Measures 2024 Consent Manual
5-B Physician Orders for Life-Sustaining Treatment (POLST) 2024 Consent Manual
6-1 Blood Test Request by Peace Officer 2024 Consent Manual, California Health Information Privacy Manual
6-2 Medical Evaluation Request by Peace Officer 2024 Consent Manual, California Health Information Privacy Manual
6-3 Warrantless Medical Search Request by Peace Officer (When Subject Refuses to Consent) 2024 Consent Manual
7-1 Experimental Subject’s Bill of Rights 2024 Consent Manual
8-1 Conditions of Admission 2024 Consent Manual
8-2 Notice of Lien 2024 Consent Manual
8-3 Assignment of Proceeds of Claim 2024 Consent Manual
8-4 Mutual Arbitration Agreement 2024 Consent Manual
8-5 Sample Arbitration Clause 2024 Consent Manual
9-1 Patient Refusal of Transfer 2024 Consent Manual
9-2 Transfer Summary (Transfer From Acute Hospital to SNF) 2024 Consent Manual
9-3 Consent to Transfer for Medical Treatment 2024 Consent Manual
9-4 Physician Certification 2024 Consent Manual
9-5 Physician Authorization for Transfer 2024 Consent Manual
9-6 Patient Refusal of Further Medical Treatment 2024 Consent Manual
9-7 Patient Transfer Acknowledgment 2024 Consent Manual
9-8 Patient Request for Transfer or Discharge 2024 Consent Manual
9-9 Notice for Emergency Room 2024 Consent Manual, Hospital Compliance Manual 2025
9-10 Temporary Absence Release 2024 Consent Manual