Forms and Appendices

Model forms, appendices, signs and handouts

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.

NOTE: The Office of Civil Rights requires many forms to include taglines regarding the availability of forms in multiple languages. Click here for details.

Form NumberForm NameAssociated Manual(s)
 Model Hospital Compliance PlanCalifornia Hospital Compliance Manual
HC 1-AAcknowledgment of Receipt of Hospital Compliance Plan California Hospital Compliance Manual
HC 1-BConflict of Interest Certification Form California Hospital Compliance Manual
HC 5-AHospital and Hospital Health Care Complex Cost Report Certification and Settlement SummaryCalifornia Hospital Compliance Manual
HC 6-AGroup Practice DefinitionCalifornia Hospital Compliance Manual
HC 7-ASample Disclosure Regarding Ambulance ReplenishingCalifornia Hospital Compliance Manual
HC 9-ARebuttable Presumption Procedure is Key to Easy Intermediate Sanctions ComplianceCalifornia Hospital Compliance Manual
HC 9-BSummary of Significant Factors Determining the Permissibility of Participation in PartnershipCalifornia Hospital Compliance Manual
HC 10-AList of Generally Required Forms for Hospital Licensure ApplicationCalifornia Hospital Compliance Manual
HC 10-BList of Miscellaneous LicensesCalifornia Hospital Compliance Manual
HC 11-AOIG Special Advisory Bulletin: The Effect of Exclusion From Participation in Federal Health Care Programs (Sept. 30, 1999)California Hospital Compliance Manual
HC 11-BCMS State Medicaid Director LetterCalifornia Hospital Compliance Manual
HC 11-CState Medicaid Excluded Provider ListCalifornia Hospital Compliance Manual
HC 12-CNotice of Community Service Obligation (CHFCLI)California Hospital Compliance Manual
HC 12-DNotice of Community Service Obligation (CHFFA)California Hospital Compliance Manual
HC 12-ENotice of Hill-Burton ObligationCalifornia Hospital Compliance Manual
HC 12-FNutritional AdviceCalifornia Hospital Compliance Manual
HC 12-GPatient Rights: Patients in General Acute Care Hospitals (State)California Hospital Compliance Manual
HC 12-HReferrals: It’s Your ChoiceCalifornia Hospital Compliance Manual
HC 15-AOIG’s Provider Self-Disclosure Protocol (October 30, 1998)California Hospital Compliance Manual
HC 15-BOIG’s Provider Self-Disclosure Protocol (April 17, 2013)California Hospital Compliance Manual
FAP 2Comparison of California and IRS Requirements for Community Health Needs Assessments and PlansHospital Financial Assistance Policies and Community Benefit Laws
California Hospital Compliance Manual
FAP 3Comparison of California and IRS Requirements Regarding Financial Assistance PoliciesHospital Financial Assistance Policies and Community Benefit Laws, California Hospital Compliance Manual
1-APatient Rights (Combines Title 22 and other California laws, The Joint Commission and Medicare Conditions of Participation requirements)Consent Manual, California Hospital Compliance Manual
4-BBe Informed (Breast Cancer)Consent Manual, California Hospital Compliance Manual
4-CBe Informed (Prostate Cancer)Consent Manual, California Hospital Compliance Manual
9-9Notice for Emergency RoomConsent Manual, California Hospital Compliance Manual, EMTALA
10-ABaby Stalking SignConsent Manual, California Hospital Compliance Manual, Minors & Healthcare Law
10-BSafe Surrender Site SignConsent Manual, California Hospital Compliance Manual, Minors & Healthcare Law
10-CObstetrical Care NoticeConsent Manual, California Hospital Compliance Manual, EMTALA, Minors & Healthcare Law
13-1Rights of PatientsCalifornia Hospital Compliance Manual
20-1Adverse Event Report Form – SampleConsent Manual, California Hospital Compliance Manual, Mental Health Law, Healthcare Workplace Violence Prevention
1-1Consent to Surgery or Special ProcedureConsent Manual, Mental Health Law, Minors & Healthcare Law
1-2Informed Consent to Surgery or Special ProcedureConsent Manual, Mental Health Law, Minors & Healthcare Law
2-1Self-Sufficient Minor InformationConsent Manual, Mental Health Law, Minors & Healthcare Law
2-2Caregiver’s Authorization AffidavitConsent Manual, Mental Health Law, Minors & Healthcare Law
2-3Authorization for Third Party to Consent for Treatment of Minor Lacking Capacity to ConsentConsent Manual, Mental Health Law, Minors & Healthcare Law
2-ADecision Makers for Medical Treatment of AdultsConsent Manual, Mental Health Law
2-BConsent Requirements for Medical Treatment of MinorsConsent Manual, Minors & Healthcare Law, Mental Health Law, Minors & Healthcare Law
2-CSelection of Health Care Surrogates With the Assistance of Health Care Professionals – Sample PolicyConsent Manual
2-DHealth Care Decisions for Unrepresented PatientsConsent Manual, Mental Health Law
2-EConsiderations for Revising the Hospital’s Policy and Procedure Regarding Decision Making for Unrepresented PatientsConsent Manual, Mental Health Law
3-1Advance Health Care DirectiveConsent Manual
4-1Transfusion Information FormConsent Manual
4-3Authorization for and Consent to HysterectomyConsent Manual
4-4Employee or Medical Staff Member StatementConsent Manual, Minors & Healthcare Law
4-5Release from Responsibility for Treatment of Miscarriage or Partial AbortionConsent Manual, Minors & Healthcare Law
4-6Consent to Reuse of Hemodialysis FiltersConsent Manual
4-7Consent to Receive Antipsychotic MedicationsConsent Manual, Mental Health Law, Minors & Healthcare Law
4-8Consent to Donation of Sperm, Ova or EmbryosConsent Manual
4-9Consent to Implantation of Sperm, Ova or EmbryosConsent Manual
4-11Directive Regarding Embryo DispositionConsent Manual
4-AA Patient’s Guide to Blood TransfusionConsent Manual
5-1Refusal to Permit Medical TreatmentConsent Manual, EMTALA, Minors & Healthcare Law
5-2Refusal of Blood ProductsConsent Manual, Minors & Healthcare Law
5-3Leaving Hospital Against Medical AdviceConsent Manual, Minors & Healthcare Law
5-4Request Regarding Resuscitative MeasuresConsent Manual, Minors & Healthcare Law
5-5Request for an Aid-in-Dying Drug to End My Life in a Humane and Dignified MannerConsent Manual
5-6Final Attestation for an Aid-in-Dying Drug to End My Life in a Humane and Dignified MannerConsent Manual
5-7End of Life Option Act Attending Physician Checklist & Compliance FormConsent Manual
5-8End of Life Option Act Attending Physician Compliance FormConsent Manual
5-9End of Life Option Act Attending Physician Follow-Up FormConsent Manual
5-AGuidelines for Policies Pertaining to Withholding and Withdrawing Life-Sustaining TreatmentConsent Manual, Minors & Healthcare Law
5-BPhysician Orders for Life-Sustaining Treatment (POLST)Consent Manual, Minors & Healthcare Law
6-1Blood Test Request by Peace OfficerConsent Manual, Minors & Healthcare Law
6-2Medical Evaluation Request by Peace OfficerConsent Manual, Minors & Healthcare Law
6-3Warrantless Medical Search Request by Peace Officer (When Subject Refuses to Consent)Consent Manual, Minors & Healthcare Law
6-ACollection and Handling of Blood Samples (Pursuant to Vehicle Code Section 23612)Consent Manual, Minors & Healthcare Law
7-1Experimental Subject’s Bill of RightsConsent Manual
8-1Conditions of AdmissionConsent Manual, Mental Health Law, Minors & Healthcare Law
8-2Notice of LienConsent Manual
8-3Assignment of Proceeds of ClaimConsent Manual
8-4Mutual Arbitration AgreementConsent Manual
8-5Sample Arbitration ClauseConsent Manual
9-1Patient Refusal of TransferConsent Manual, EMTALA
9-2Transfer Summary (Transfer from Acute Hospital to SNF)Consent Manual, EMTALA
9-3Consent to Transfer for Medical TreatmentConsent Manual, EMTALA
9-4Physician CertificationConsent Manual, EMTALA
9-5Physician Authorization for TransferConsent Manual, EMTALA
9-6Patient Refusal of Further Medical TreatmentConsent Manual, EMTALA
9-7Patient Transfer AcknowledgmentConsent Manual, EMTALA
9-8Patient Request for Transfer or DischargeConsent Manual, EMTALA
9-10Temporary Absence ReleaseConsent Manual
9-11Consent for Participation in Patient OutingConsent Manual
10-1Authorization for Release of a MinorConsent Manual, Minors & Healthcare Law
10-2Acknowledgment of Release of a MinorConsent Manual, Minors & Healthcare Law
10-3Release of a Child Under 8 Years of AgeConsent Manual, Minors & Healthcare Law
10-4Newborn Family Medical History QuestionnaireConsent Manual, Minors & Healthcare Law
10-5Refusal to Permit Rho(D)-Immune Globulin AdministrationConsent Manual, Minors & Healthcare Law
10-6Refusal to Permit Administration of an Approved Prophylactic Agent to the Eyes of NewbornConsent Manual, Minors & Healthcare Law
10-7Consultation Regarding Length of Stay After ChildbirthConsent Manual, Minors & Healthcare Law
11-1Authorization for AutopsyConsent Manual
11-2Authorization for Anatomical GiftConsent Manual
11-3Delivery of Personal Property of Deceased PatientConsent Manual
12-1Request for Voluntary Admission and Authorization for TreatmentConsent Manual, Mental Health Law
12-2Statement of Professional Person Responsible for Minor’s AdmissionConsent Manual, Mental Health Law, Minors & Healthcare Law
12-3Notice to MinorsConsent Manual, Mental Health Law, Minors & Healthcare Law
12-4Certificate of Admitting PhysicianConsent Manual, Mental Health Law
12-5Application of Involuntary Admission – InebriatesConsent Manual, Mental Health Law
12-6Notice of Certification for Intensive TreatmentConsent Manual, Mental Health Law
12-7Advisement of Rights – Involuntary PatientConsent Manual, Mental Health Law
12-8Leave of Absence from Psychiatric ServiceConsent Manual, Mental Health Law
12-9Request for Release from Involuntary TreatmentConsent Manual, Mental Health Law
12-10Notice of Certification to Second Involuntary 14-Day Period for Intensive Treatment – Suicidal PatientConsent Manual, Mental Health Law
12-11Petition for Postcertification Treatment of Imminently Dangerous PersonConsent Manual, Mental Health Law
12-12Detention of Patient with Psychiatric Emergency in a Nondesignated Health Facility (Health and Safety Code Section 1799.111)Consent Manual, Mental Health Law, Minors & Healthcare Law
12-ASummary of the Lanterman-Petris-Short Act’s Provisions for Involuntary Evaluation and Treatment and Right of ReviewConsent Manual, Mental Health Law
13-3Aftercare PlanConsent Manual, Mental Health Law
13-4Notice to Law Enforcement Agency: Release of Person From Hospital From Whom a Firearm or Other Deadly Weapon Was ConfiscatedConsent Manual, Mental Health Law
13-5Notice to Patient: Procedure for Return of Confiscated Weapon(s)Consent Manual, Mental Health Law
14-1Agreement for Facsimile Transmission of Psychiatric RecordsConsent Manual
16-1Authorization for Use or Disclosure of Health InformationConsent Manual, California Health Information Privacy Manual, Mental Health Law, Minors & Healthcare Law
16-2Request to Withhold Public Release of InformationConsent Manual, California Health Information Privacy Manual
19-2Employee Acknowledgment of Child Abuse and Neglect Reporting ObligationsConsent Manual, Mental Health Law, Minors & Healthcare Law
19-3Report of Injury or Condition Resulting From Neglect or Abuse (To a Patient Received From a Licensed Health Facility)Consent Manual
19-4Employee Acknowledgment of Elder and Dependent Adult Abuse Reporting ObligationsConsent Manual, Mental Health Law
19-AAssault and Abuse Reporting RequirementsConsent Manual, Mental Health Law
21-1Incident ReportConsent Manual
21-2Report to AttorneyConsent Manual
23-1Consent for the HIV TestConsent Manual, Mental Health Law, Minors & Healthcare Law
23-2Refusal to Consent to Communicable Disease Testing/Refusal to Receive Results of Communicable Disease TestingConsent Manual
24-1Release of Side RailsConsent Manual
24-2Permit for Using Electrical AppliancesConsent Manual
24-3Consent to PhotographConsent Manual
24-4Consent to Photograph and Authorization for Use and DisclosureConsent Manual
24-5Request for Presence of Observer During Childbirth/Medical ProcedureConsent Manual, California Health Information Privacy Manual, Minors & Healthcare Law
25-AReport of a Hospital Death Associated With Restraint or SeclusionConsent Manual, Mental Health Law
19-1Assault or Battery Against Hospital PersonnelHealthcare Workplace Violence Prevention
DP 1-AHomeless Patient Discharge Planning WorksheetDischarge Planning for Homeless Patients
DP 1-BQuestionnaire to Determine Whether a Patient is Homeless as Defined in State LawDischarge Planning for Homeless Patients
DP 1-CDocumentation of Homeless Patient Discharge Planning TrainingDischarge Planning for Homeless Patients
DP Appendix ACalifornia’s Discharge Planning LawDischarge Planning for Homeless Patients
DP Appendix BMedicare Condition of Participation for Discharge PlanningDischarge Planning for Homeless Patients
DP Appendix CSample Language for Homeless Patient Discharge Planning PolicyDischarge Planning for Homeless Patients
DP Appendix DRegional Vice President Geographical DistributionDischarge Planning for Homeless Patients
Related