Commonly Used Forms
To help make things easier, we have one area that features commonly used forms that you may need when using one of Hoag’s facilities.
Forms:
- Advance Health Care Directive (English)
- Advance Health Care Directive (Spanish)
- Authorization to Release Copies of Medical Records (English)
- Autorizacion Para Obtener Copias de Expediente Medico (Español)
- Authorization To Provide Mammo & Radiology Films
- Bone Densitometry Questionaire
- Conditions of Admission (Inpatient)
- Conditions of Admission (Outpatient)
- Conditions of Admission (Arabic)
- Conditions of Admission (Chinese)
- Conditions of Admission (Farsi)
- Conditions of Admission (Korean)
- Conditions of Admission (Spanish)
- Conditions of Admission (Vietnamese)
- CT Outpatient Questionnaire
- Diagnostic Outpatient Questionnaire
- Hysterosalpingography Questionnaire
- Medicare Rights (NS 80751)
- Medicare Secondary Payer Questionnaire (PS 138)
- MRI Outpatient Questionnaire
- MRI Safety Checklist
- Outpatient Medication Reconciliation (for Breast Center and Interventional Procedures)
- Outpatient Medication Reconciliation
- Patient History Questionnaire
- PET Patient Questionnaire
- Pre-Procedure Patient Self-Assessment (PS 1724)
- Prostate Ultrasound Questionnaire
- Pulmonary Function testing questionnaire
- Request to Amend Protected Health Information (PS 2049)
- Stress Test Questionnaire
California Immunization Registry
Hoag may share your immunization or tuberculosis (TB) screening test records with the California Immunization Registry (CAIR), a statewide, secure and confidential database of patient immunization information. The CAIR is used by health care professionals, agencies, and schools to keep track of all shots and TB tests you take, and can provide proof about immunizations needed to start child care, school, or a new job. If you do not want your immunization or TB records to be shared with other registry users, please fax or email the “Decline or Start Sharing/Immunization Information Request Form,” available on the CAIR website at http://cairweb.org/cair-forms/, to the CAIR Help Desk at 1-888-436-8320 or CAIRHelpDesk@cdph.ca.gov.