Attachment 7 Against Medical Advice Form.docx
DOCX document 20 KB Posted
- Attached to
- ENTERPRISE HEALTH UNIT SERVICES
- Solicitation number
- 70LGLY26RGLB00001
About this file
This file is a template form for patient documentation in a medical facility context. Specifically, it is an Against Medical Advice (AMA) Form used when patients refuse medical treatment or request discharge against physician recommendations. The form documents the patient's voluntary decision to leave the medical center and releases the facility, its administration, medical staff, and attending physicians from liability for any resulting consequences.
The form requires completion of patient and physician information, including patient name, hospital name, and attending physician name. It includes checkboxes for patients to acknowledge specific medical risks (such as death, additional pain and suffering, permanent disability, risks to unborn fetus, and other complications) and medical benefits they are forgoing (including history and physical examinations, radiological imaging, laboratory testing, medications, and potential admission or follow-up care). The form requires signatures from the patient, physician, and a witness, along with corresponding dates. While this form is included as Attachment 7 in the solicitation materials for Enterprise Health Unit Services at DHS Federal Law Enforcement Training Centers, the form itself is a standard medical document template rather than a specification of services or requirements for the contract opportunity.
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Text version
AGAINST MEDICAL ADVICE (AMA FORM)
This is to certify that I, ________________________________________, a patient at __________________________________________(fill in name of your hospital), am refusing at my own insistence and without the authority of and against the advice of my attending physician(s)
_______________________________________, request to leave against medical advice.
The medical risks/benefits have been explained to me by a member of the medical staff and I understand those risks.
I hereby release the medical center, its administration, personnel, and my attending and/or resident physician(s) from any responsibility for all consequences, which may result by my leaving under these circumstances.
MEDICAL RISKS
_____Death _____Additional pain and/or suffering
_____Risks to unborn fetus _____Permanent disability/disfigurement
_____Other:___________________________________________________
MEDICAL BENEFITS
_____ History/physical examination, further additional testing and treatment as indicated.
_____ Radiological imaging such as:
_____CAT scan ____X-rays ____ ultrasound (sonogram)
_____ Laboratory testing _____ Potentional admission and/or follow-up _____ Medications as indicated for infection, pain, blood pressure, etc.
_____Other:____________________________________________
Please return at any time for further testing or treatment
| Patient Signature_______________________ |
| Date_______________ |
| Physician Signature_____________________ |
| Date_______________ |
| Witness ______________________________ |
| Date_______________ |
Health Services Contract Part 9, Attachment 7
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File details come from the government source that posted it. Updated .