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Publications


Forms & Posters

You may download the forms and posters below for your use. Printed posters may be also be purchased online.

Patient Forms and Handouts

A Patient's Guide to Blood Transfusion (3/09)

     English

     Spanish

PDF

PDF

Refusal to Permit Blood Transfusion (4/09)

     English

     Spanish

PDF
Word
Advance Health Care Directive Form (2/08) English

PDF
Word

Advance Health Care Directive Form (2/08) Spanish PDF
Word
Adverse Event Report Form (3/09)

PDF
Word

Authorization for Use or Disclosure of Medical Information (6/03)

PDF
Word

Child Safety Seat Form (3/09) (English/Spanish)

PDF
Word

Conditions of Admission Form (3/08) (English/Spanish)

PDF
Word

Consent to Photograph (4/05)

PDF
Word

Consent to Surgery or Special Procedure (3/09)

PDF
Word

Informed Consent to Surgery or Special Procedure (3/09) PDF
Word
Never Shake a Baby (1/04) Download
ordering
information

English

Spanish
Model Notice of Privacy Practices, Acknowledgement of Receipt (3/03) PDF
Word
Model Notice of Privacy Practices, General Patient (3/09) PDF
Word
Model Notice of Privacy Practices, Mental Health Patient (3/09) PDF
Word
Patient Notice of Financial Assistance (4/05) PDF
Word

Posters

Baby Stalking Prohibited—Restricted Access (English/Spanish)
"Be Informed" Breast Cancer Poster (3/08)
"Be Informed" Prostate Cancer Poster (3/08)
EMTALA "It's the Law" Poster (English/Spanish)
EMTALA Maternity Care Poster
Financial Assistance Notice (4/05)
Patient Rights Poster (3/08) (English/Spanish)

Safe Surrender Site

Posters and brochures are availabe free of charge from the Department of Social Services. Include the name of your organziation, address, quantity and if you want Spanish or English.

Fax order to 916.371.3518 or email admbsbwh@dss.ca.gov.

Click here for more Safely Surrendered Baby information.

 

Quick Reference Guides for Hospital Staff

Assault and Abuse Reporting Requirements (3/08)
Consent Requirements for Medical Treatment of Adults (3/09)
Consent Requirements for Medical Treatment of Minors (3/09)

 

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