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 151 - 175 of 209 results

Form Number Form Name Associated Manual(s)
HC 12-F Nutritional Advice Mental Health Law Manual, Hospital Compliance Manual
HC 12-H Referrals: It’s Your Choice Mental Health Law Manual, Hospital Compliance Manual
HC 7-A Sample Disclosure Regarding Ambulance Replenishing Mental Health Law Manual, Hospital Compliance Manual
HC 9-B Summary of Significant Factors Determining the Permissibility of Participation in Partnership Mental Health Law Manual, Hospital Compliance Manual
HS 1 California Department of Public Health Organization Chart California Hospital Survey Manual
HS 10 Sample Cover Letter for Hospital’s CMS-2567 Response California Hospital Survey Manual
HS 11 Definitions of Hospitals Under California Law California Hospital Survey Manual
HS 13 FAQs on Writing Hospital Policies and Procedures California Hospital Survey Manual
HS 14 Instructions for Calculating an Administrative Penalty California Hospital Survey Manual
HS 15 Federal vs. State Immediate Jeopardy Definition and Implementation Comparison California Hospital Survey Manual
HS 4 Unusual Occurrences Reporting Requirement California Hospital Survey Manual
HS 5 State-2567: Statement of Deficiencies and Plan of Correction California Hospital Survey Manual
HS 6 Maximum Time Frames Related to the Federal On-Site Investigation of Complaints/Incidents California Hospital Survey Manual
HS 7 Form CMS-2567: Statement of Deficiencies and Plan of Correction California Hospital Survey Manual
HS 8 Timeline for 90-Day Termination Track California Hospital Survey Manual
HS 9 Timeline for 23-Day Termination Track California Hospital Survey Manual
PR 1-A Acronyms 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
PR 10-A HIPAA Security Standards Matrix California Health Information Privacy Manual
PR 11-B Business Associate Addendum California Health Information Privacy Manual
PR 12-A Federal and State Breach Notification Laws for California California Health Information Privacy Manual
PR 12-B HIPAA Breach Decision Tool and Risk Assessment Documentation Form California Health Information Privacy Manual
PR 12-C Questionnaire and Confidentiality Agreement California Health Information Privacy Manual
PR 12-D Questionnaire and Confidentiality Agreement (Electronic PHI) California Health Information Privacy Manual