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)
12-12 Detention of Patient With Psychiatric Emergency in a Nondesignated Health Facility (Health and Safety Code Section 1799.111) Consent Manual
12-A Summary of Lanterman-Petris-Short Act’s Provisions for Involuntary Evaluation and Treatment and Right of Review Consent Manual
13-3 Aftercare Plan Consent Manual
13-4 Notice to Law Enforcement Agency: Release of Person From Hospital From Whom a Firearm or Other Deadly Weapon Was Confiscated Consent Manual
13-5 Notice to Patient: Procedure for Return of Confiscated Weapon(s) Consent Manual
14-1 Agreement for Facsimile Transmission of Psychiatric Records Consent Manual
15-1 Notice of Privacy Practices: Acknowledgement of Receipt Consent Manual, California Health Information Privacy Manual
15-2 Model Notice of Privacy Practices Consent Manual, California Health Information Privacy Manual
15-3 Model Notice of Privacy Practices (For Mental Health Information Subject to the Lanterman-Petris-Short Act) Consent Manual, California Health Information Privacy Manual
16-1 Authorization for Use or Disclosure of Health Information Consent Manual, California Health Information Privacy Manual
16-2 Request to Withhold Public Release of Information Consent Manual, California Health Information Privacy Manual
19-1 Assault or Battery Against Hospital Personnel Healthcare Workplace Violence Prevention
19-2 Employee Acknowledgment of Child Abuse and Neglect Reporting Obligations 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
19-4 Employee Acknowledgment of Elder and Dependent Adult Abuse Reporting Obligations Consent Manual
19-A Assault and Abuse Reporting Requirements Consent Manual
21-1 Incident Report Consent Manual
21-2 Report to Attorney Consent Manual
23-1 Consent to the HIV Test Consent Manual
23-2 Refusal to Consent to Communicable Disease Testing/Refusal to Receive Results of Communicable Disease Testing Consent Manual
24-1 Release of Side Rails Consent Manual
24-2 Permit for Using Electrical Appliances Consent Manual
24-3 Consent to Photograph Consent Manual, California Health Information Privacy Manual
24-4 Consent to Photograph and Authorization for Use and Disclosure Consent Manual
24-5 Request for Presence of Observer During Childbirth/Medical Procedure Consent Manual, California Health Information Privacy Manual