Attachment D.docx

Attachment D VISN 12 Against Medical Advice (AMA) Form

Patient Name: _____ Last 4 of SSN: _____

DOB: ___________

PATIENT DECISION:

I refuse ALL oxygen related equipment at this time I refuse to have BACK-UP oxygen equipment in my home Other equipment covered by this decision:

I am accepting equipment that does not allow me to be compliant with my physician’s order, and I understand the risk involved. Details:

PATIENT STATEMENT:

As part of my ongoing plan of care, my physician has ordered the use of the above equipment which has been deemed necessary for the treatment of my medical condition. I have made the decision not to accept delivery of the equipment ordered by my physician for the following reason(s):

I wish to refuse the equipment listed above because:

The decision indicated above is my decision, and I am making this decision AGAINST MEDICAL ADVICE. The consequences of my decision have been explained to me and I understand them. I assume full responsibility for the consequences of this decision and release the VA and its agents from all liability associated with my decision. The contractor shall submit scanned versions of completed AMA forms via encrypted e-mail to the applicable ORPC/Prosthetics Department no later than the next business day.

Patient Signature:

Date:

Employee Signature:

Date:

VA 1624 Clinical Respiratory Assessment – Vent (VISN 12) Rev 6/4/2020 image1.png