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 126 - 150 of 209 results

Form Number Form Name Associated Manual(s)
Appendix T Sample Transfer Checklist and Script for Accepting Emergency Patients EMTALA Manual
Appendix U CDPH All-Facility Letter 12-17 (May 17, 2012) EMTALA Manual
Appendix V CMS Letter Regarding Transfer of Patients to Crisis Stabilization Units EMTALA Manual
Appendix W EMTALA Physician Review Worksheet EMTALA Manual
Appendix X CMS Survey and Certification Memorandum 14-06: EMTALA Requirements & Conflicting Payor Requirements or Collection Practices (Dec. 13, 2013) EMTALA Manual
Appendix Y CMS Survey and Certification Memorandum 13-38: Critical Access Hospital Emergency Services and Telemedicine (June 7, 2013) EMTALA 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
DP 1-A Homeless Patient Discharge Planning Worksheet The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
DP 1-B Sample Questionnaires to Determine Whether a Patient is Homeless as Defined in State Law The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
DP 1-C Documentation of Homeless Patient Discharge Planning Training 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
DP Appendix A California’s Discharge Planning Law The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
DP Appendix B Medicare Conditions of Participation for Discharge Planning The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
DP Appendix C Sample Language for Homeless Patient Discharge Planning Policy The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
DP Appendix D Regional Vice President Geographical Distribution The Cal/OSHA Safe Patient Handling Regulation, Discharge Planning for Homeless Patients
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
HC 1-A Acknowledgment of Receipt of Hospital Compliance Plan Mental Health Law Manual, Hospital Compliance Manual
HC 1-B Conflict of Interest Certification Form Mental Health Law Manual, Hospital Compliance Manual
HC 10-B List of Miscellaneous Licenses Mental Health Law Manual, Hospital Compliance Manual
HC 11-B CMS State Medicaid Director Letter Mental Health Law Manual, Hospital Compliance Manual
HC 11-C State Medicaid Excluded Provider List Mental Health Law Manual, Hospital Compliance Manual
HC 12-C Notice of Community Service Obligation (CHFCLI) Mental Health Law Manual, Hospital Compliance Manual
HC 12-D Notice of Community Service Obligation (CHFFA) Mental Health Law Manual, Hospital Compliance Manual
HC 12-E Notice of Hill-Burton Obligation Mental Health Law Manual, Hospital Compliance Manual