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.

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Showing 101 - 125 of 209 results

Form Number Form Name Associated Manual(s)
25-A Report of Hospital Death Associated With Restraint or Seclusion Consent Manual
Appendix 9-A Medical Necessity for MHP Coverage Consent Manual
Appendix 9-B Types of MCPs and MHPs Consent Manual
Appendix 9-D DHCS Chart: Medi-Cal Mental Health Services Consent Manual
Appendix 9-E Pertinent Legal Definitions of Emergency Psychiatric Conditions Consent Manual
Appendix A EMTALA Statute 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 B EMTALA and Emergency-Related Federal Regulations EMTALA Manual
Appendix C EMTALA Interpretive Guidelines (Part II: Responsibilities of Medicare Participating Hospitals in Emergency Cases) EMTALA Manual
Appendix D California Hospital Licensing Laws on Emergency Services and Care EMTALA Manual
Appendix E CoP for Emergency Services: Hospital Interpretive Guidelines EMTALA Manual
Appendix F Knox-Keene Act Provisions EMTALA Manual
Appendix G Medicare Advantage Regulations EMTALA Manual
Appendix H Special Advisory Bulletin EMTALA Manual
Appendix I EMTALA Enforcement Chart EMTALA Manual
Appendix J Hospital Records Subject to EMTALA Enforcement Survey EMTALA Manual
Appendix K Investigative Procedures for EMTALA Surveyors EMTALA Manual
Appendix L Sample Survey Tools for Patient Transfers and Medical Screening Examinations EMTALA Manual
Appendix M An Explanation of the Scope of RN Practice Including Standardized Procedures EMTALA Manual
Appendix N Policies Recommended for EMTALA Compliance EMTALA Manual
Appendix O Model Hospital Policy on Compliance with EMTALA EMTALA Manual
Appendix P CHA Transfer Forms and Model Signage 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 S Sample Transfer Agreement EMTALA Manual