Appendix 5-8 MDG Form O-16 Waiver of Ambulance Service and Government Liability.doc

FA4801-11-R-0002

Ambulance Service

WAIVER OF AMBULANCE SERVICE AND GOVERNMENT LIABILITY

49th Medical Group

Holloman AFB, NM

FROM:_______________________________

(PATIENT/GUARDIAN)

Initial.( )

I recognize that an ambulance has been dispatched to transport me or my legal dependent to the nearest emergency room, at Gerald Champion Regional Medical Center in

Alamogordo, Nm. I recognize that by declining this transport, I hereby absolutely release Holloman AFB, NM and the United States Government from any complication or injuries which may result as a consequence of my refusing transportation to the emergency room in Alamogordo.

In recognition of the above stated facts, I am signing this RELEASE OF LIABILITY of my own accord and acknowledgement that I have been informed of the potential risk involved by not seeking medical attention or transport at this time.

Patient Name:______________________ Signature:____________________________ __________

(print) (patient/guardian) (date/time)

Sponsor SSN:____/_______-_____-________

Witness Name:______________________ Signature:____________________________ __________

(print) (date/time)

Witness Name:______________________ Signature:____________________________ __________

(print) (date/time

This is AGAINST MEDICAL ADVICE: YES NO

MEDICAL CONTROL CONTACTED: YES

NO

( This form is subject to the Privacy Act of 1974 – Use DD Form 2005 ) MDG Form O-16 20030220 Patient’s Record 10 May 2011 Appendix 5-8