Section 1 - Facility Site Review Overview
Section 2 - Facility Site Review Forms
- Authorization to Release Healthcare Information (DHCS Form)
- Autoclave Logs
- Controlled Drug Inventory
- Emergency Contact List
- Emergency Drug/Medication Inventory Log
- Emergency Earthquake Plan
- Emergency Fire Plan
- Emergency Supplies Inventory Checklist
- Expired Drug Log
- Facility Site Review Self-Assessment
- Glucometer Quality Control Log
- Medical Emergency Protocol
- Monthly Medication Verification Log and Equipment Log
- Notice to Consumers
- Office Cleaning Schedule
- Office Staff Signature Page
- Patient Grievance Log
- Referral Log
- Refrigerator and Freezer Temperature Log
- Sharps Injury Logs
- Site Evacuation Plan Sample
- Staff Education Checklist
- UnitedHealthcare Health Education Order Form
- Use and Maintenance of Medical Equipment
- Work Violence Protocol
Section 3 - Medical Record Review Forms
- Adult Preventive Care Flow Sheet
- Bright Futures Pediatric Periodicity Schedule
- CDC Adult BMI Resources
- CDC Adult Immunization Schedule (19+ Years of Age)
- CDC Children and Adolescent BMI Tables
- CDC Growth Charts
- CDC Pediatric Immunization Schedule (0-18 Years of Age)
- DHCS Stay Health Assessment Resources and Forms
- Medical Record Review Self-Assessment Checklist
- Patient Chronic Diagnosis/Problem List
- Patient Language and Linguistic Information Form
- Patient Medication List Log
- Patient Registration Form
- Tuberculosis Risk Assessment
- WIC Fact Sheet
Section 4 - Physical Accessibility Review Survey Regulations
If you need additional resources or have questions, please email the California Community Plan Quality Department at UHCCSCAQualityDepartment_DL@ds.uhc.com.