| Model Hospital Compliance Plan | California Hospital Compliance Manual |
HC 1-A | Acknowledgment of Receipt of Hospital Compliance Plan | California Hospital Compliance Manual |
HC 1-B | Conflict of Interest Certification Form | California Hospital Compliance Manual |
HC 5-A | Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary | California Hospital Compliance Manual |
HC 6-A | Group Practice Definition | California Hospital Compliance Manual |
HC 7-A | Sample Disclosure Regarding Ambulance Replenishing | California Hospital Compliance Manual |
HC 9-A | Rebuttable Presumption Procedure is Key to Easy Intermediate Sanctions Compliance | California Hospital Compliance Manual |
HC 9-B | Summary of Significant Factors Determining the Permissibility of Participation in Partnership | California Hospital Compliance Manual |
HC 10-A | List of Generally Required Forms for Hospital Licensure Application | California Hospital Compliance Manual |
HC 10-B | List of Miscellaneous Licenses | California Hospital Compliance Manual |
HC 11-A | OIG Special Advisory Bulletin: The Effect of Exclusion From Participation in Federal Health Care Programs (Sept. 30, 1999) | California Hospital Compliance Manual |
HC 11-B | CMS State Medicaid Director Letter | California Hospital Compliance Manual |
HC 11-C | State Medicaid Excluded Provider List | California Hospital Compliance Manual |
HC 12-C | Notice of Community Service Obligation (CHFCLI) | California Hospital Compliance Manual |
HC 12-D | Notice of Community Service Obligation (CHFFA) | California Hospital Compliance Manual |
HC 12-E | Notice of Hill-Burton Obligation | California Hospital Compliance Manual |
HC 12-F | Nutritional Advice | California Hospital Compliance Manual |
HC 12-G | Patient Rights: Patients in General Acute Care Hospitals (State) | California Hospital Compliance Manual |
HC 12-H | Referrals: It’s Your Choice | California Hospital Compliance Manual |
HC 15-A | OIG’s Provider Self-Disclosure Protocol (October 30, 1998) | California Hospital Compliance Manual |
HC 15-B | OIG’s Provider Self-Disclosure Protocol (April 17, 2013) | California Hospital Compliance Manual |
FAP 2 | Comparison of California and IRS Requirements for Community Health Needs Assessments and Plans | Hospital Financial Assistance Policies and Community Benefit Laws California Hospital Compliance Manual |
FAP 3 | Comparison of California and IRS Requirements Regarding Financial Assistance Policies | Hospital Financial Assistance Policies and Community Benefit Laws, California Hospital Compliance Manual |
1-A | Patient Rights (Combines Title 22 and other California laws, The Joint Commission and Medicare Conditions of Participation requirements) | Consent Manual, California Hospital Compliance Manual |
4-B | Be Informed (Breast Cancer) | Consent Manual, California Hospital Compliance Manual |
4-C | Be Informed (Prostate Cancer) | Consent Manual, California Hospital Compliance Manual |
9-9 | Notice for Emergency Room | Consent Manual, California Hospital Compliance Manual, EMTALA |
10-A | Baby Stalking Sign | Consent Manual, California Hospital Compliance Manual, Minors & Healthcare Law |
10-B | Safe Surrender Site Sign | Consent Manual, California Hospital Compliance Manual, Minors & Healthcare Law |
10-C | Obstetrical Care Notice | Consent Manual, California Hospital Compliance Manual, EMTALA, Minors & Healthcare Law |
13-1 | Rights of Patients | California Hospital Compliance Manual |
20-1 | Adverse Event Report Form – Sample | Consent Manual, California Hospital Compliance Manual, Mental Health Law, Healthcare Workplace Violence Prevention |
1-1 | Consent to Surgery or Special Procedure | Consent Manual, Mental Health Law, Minors & Healthcare Law |
1-2 | Informed Consent to Surgery or Special Procedure | Consent Manual, Mental Health Law, Minors & Healthcare Law |
2-1 | Self-Sufficient Minor Information | Consent Manual, Mental Health Law, Minors & Healthcare Law |
2-2 | Caregiver’s Authorization Affidavit | Consent Manual, Mental Health Law, Minors & Healthcare Law |
2-3 | Authorization for Third Party to Consent for Treatment of Minor Lacking Capacity to Consent | Consent Manual, Mental Health Law, Minors & Healthcare Law |
2-A | Decision Makers for Medical Treatment of Adults | Consent Manual, Mental Health Law |
2-B | Consent Requirements for Medical Treatment of Minors | Consent Manual, Minors & Healthcare Law, Mental Health Law, Minors & Healthcare Law |
2-C | Selection of Health Care Surrogates With the Assistance of Health Care Professionals – Sample Policy | Consent Manual |
2-D | Health Care Decisions for Unrepresented Patients | Consent Manual, Mental Health Law |
2-E | Considerations for Revising the Hospital’s Policy and Procedure Regarding Decision Making for Unrepresented Patients | Consent Manual, Mental Health Law |
3-1 | Advance Health Care Directive | Consent Manual |
4-1 | Transfusion Information Form | Consent Manual |
4-3 | Authorization for and Consent to Hysterectomy | Consent Manual |
4-4 | Employee or Medical Staff Member Statement | Consent Manual, Minors & Healthcare Law |
4-5 | Release from Responsibility for Treatment of Miscarriage or Partial Abortion | Consent Manual, Minors & Healthcare Law |
4-6 | Consent to Reuse of Hemodialysis Filters | Consent Manual |
4-7 | Consent to Receive Antipsychotic Medications | Consent Manual, Mental Health Law, Minors & Healthcare Law |
4-8 | Consent to Donation of Sperm, Ova or Embryos | Consent Manual |
4-9 | Consent to Implantation of Sperm, Ova or Embryos | Consent Manual |
4-11 | Directive Regarding Embryo Disposition | Consent Manual |
4-A | A Patient’s Guide to Blood Transfusion | Consent Manual |
5-1 | Refusal to Permit Medical Treatment | Consent Manual, EMTALA, Minors & Healthcare Law |
5-2 | Refusal of Blood Products | Consent Manual, Minors & Healthcare Law |
5-3 | Leaving Hospital Against Medical Advice | Consent Manual, Minors & Healthcare Law |
5-4 | Request Regarding Resuscitative Measures | Consent Manual, Minors & Healthcare Law |
5-5 | Request for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner | Consent Manual |
5-6 | Final Attestation for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner | Consent Manual |
5-7 | End of Life Option Act Attending Physician Checklist & Compliance Form | Consent Manual |
5-8 | End of Life Option Act Attending Physician Compliance Form | Consent Manual |
5-9 | End of Life Option Act Attending Physician Follow-Up Form | Consent Manual |
5-A | Guidelines for Policies Pertaining to Withholding and Withdrawing Life-Sustaining Treatment | Consent Manual, Minors & Healthcare Law |
5-B | Physician Orders for Life-Sustaining Treatment (POLST) | Consent Manual, Minors & Healthcare Law |
6-1 | Blood Test Request by Peace Officer | Consent Manual, Minors & Healthcare Law |
6-2 | Medical Evaluation Request by Peace Officer | Consent Manual, Minors & Healthcare Law |
6-3 | Warrantless Medical Search Request by Peace Officer (When Subject Refuses to Consent) | Consent Manual, Minors & Healthcare Law |
6-A | Collection and Handling of Blood Samples (Pursuant to Vehicle Code Section 23612) | Consent Manual, Minors & Healthcare Law |
7-1 | Experimental Subject’s Bill of Rights | Consent Manual |
8-1 | Conditions of Admission | Consent Manual, Mental Health Law, Minors & Healthcare Law |
8-2 | Notice of Lien | Consent Manual |
8-3 | Assignment of Proceeds of Claim | Consent Manual |
8-4 | Mutual Arbitration Agreement | Consent Manual |
8-5 | Sample Arbitration Clause | Consent Manual |
9-1 | Patient Refusal of Transfer | Consent Manual, EMTALA |
9-2 | Transfer Summary (Transfer from Acute Hospital to SNF) | Consent Manual, EMTALA |
9-3 | Consent to Transfer for Medical Treatment | Consent Manual, EMTALA |
9-4 | Physician Certification | Consent Manual, EMTALA |
9-5 | Physician Authorization for Transfer | Consent Manual, EMTALA |
9-6 | Patient Refusal of Further Medical Treatment | Consent Manual, EMTALA |
9-7 | Patient Transfer Acknowledgment | Consent Manual, EMTALA |
9-8 | Patient Request for Transfer or Discharge | Consent Manual, EMTALA |
9-10 | Temporary Absence Release | Consent Manual |
9-11 | Consent for Participation in Patient Outing | Consent Manual |
10-1 | Authorization for Release of a Minor | Consent Manual, Minors & Healthcare Law |
10-2 | Acknowledgment of Release of a Minor | Consent Manual, Minors & Healthcare Law |
10-3 | Release of a Child Under 8 Years of Age | Consent Manual, Minors & Healthcare Law |
10-4 | Newborn Family Medical History Questionnaire | Consent Manual, Minors & Healthcare Law |
10-5 | Refusal to Permit Rho(D)-Immune Globulin Administration | Consent Manual, Minors & Healthcare Law |
10-6 | Refusal to Permit Administration of an Approved Prophylactic Agent to the Eyes of Newborn | Consent Manual, Minors & Healthcare Law |
10-7 | Consultation Regarding Length of Stay After Childbirth | Consent Manual, Minors & Healthcare Law |
11-1 | Authorization for Autopsy | Consent Manual |
11-2 | Authorization for Anatomical Gift | Consent Manual |
11-3 | Delivery of Personal Property of Deceased Patient | Consent Manual |
12-1 | Request for Voluntary Admission and Authorization for Treatment | Consent Manual, Mental Health Law |
12-2 | Statement of Professional Person Responsible for Minor’s Admission | Consent Manual, Mental Health Law, Minors & Healthcare Law |
12-3 | Notice to Minors | Consent Manual, Mental Health Law, Minors & Healthcare Law |
12-4 | Certificate of Admitting Physician | Consent Manual, Mental Health Law |
12-5 | Application of Involuntary Admission – Inebriates | Consent Manual, Mental Health Law |
12-6 | Notice of Certification for Intensive Treatment | Consent Manual, Mental Health Law |
12-7 | Advisement of Rights – Involuntary Patient | Consent Manual, Mental Health Law |
12-8 | Leave of Absence from Psychiatric Service | Consent Manual, Mental Health Law |
12-9 | Request for Release from Involuntary Treatment | Consent Manual, Mental Health Law |
12-10 | Notice of Certification to Second Involuntary 14-Day Period for Intensive Treatment – Suicidal Patient | Consent Manual, Mental Health Law |
12-11 | Petition for Postcertification Treatment of Imminently Dangerous Person | Consent Manual, Mental Health Law |
12-12 | Detention 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-A | Summary of the Lanterman-Petris-Short Act’s Provisions for Involuntary Evaluation and Treatment and Right of Review | Consent Manual, Mental Health Law |
13-3 | Aftercare Plan | Consent Manual, Mental Health Law |
13-4 | Notice to Law Enforcement Agency: Release of Person From Hospital From Whom a Firearm or Other Deadly Weapon Was Confiscated | Consent Manual, Mental Health Law |
13-5 | Notice to Patient: Procedure for Return of Confiscated Weapon(s) | Consent Manual, Mental Health Law |
14-1 | Agreement for Facsimile Transmission of Psychiatric Records | Consent Manual |
16-1 | Authorization for Use or Disclosure of Health Information | Consent Manual, California Health Information Privacy Manual, Mental Health Law, Minors & Healthcare Law |
16-2 | Request to Withhold Public Release of Information | Consent Manual, California Health Information Privacy Manual |
19-2 | Employee Acknowledgment of Child Abuse and Neglect Reporting Obligations | Consent Manual, Mental Health Law, Minors & Healthcare Law |
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, Mental Health Law |
19-A | Assault and Abuse Reporting Requirements | Consent Manual, Mental Health Law |
21-1 | Incident Report | Consent Manual |
21-2 | Report to Attorney | Consent Manual |
23-1 | Consent for the HIV Test | Consent Manual, Mental Health Law, Minors & Healthcare Law |
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 |
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, Minors & Healthcare Law |
25-A | Report of a Hospital Death Associated With Restraint or Seclusion | Consent Manual, Mental Health Law |
19-1 | Assault or Battery Against Hospital Personnel | Healthcare Workplace Violence Prevention |
DP 1-A | Homeless Patient Discharge Planning Worksheet | Discharge Planning for Homeless Patients |
DP 1-B | Questionnaire to Determine Whether a Patient is Homeless as Defined in State Law | Discharge Planning for Homeless Patients |
DP 1-C | Documentation of Homeless Patient Discharge Planning Training | Discharge Planning for Homeless Patients |
DP Appendix A | California’s Discharge Planning Law | Discharge Planning for Homeless Patients |
DP Appendix B | Medicare Condition of Participation for Discharge Planning | Discharge Planning for Homeless Patients |
DP Appendix C | Sample Language for Homeless Patient Discharge Planning Policy | Discharge Planning for Homeless Patients |
DP Appendix D | Regional Vice President Geographical Distribution | Discharge Planning for Homeless Patients |