Release from Responsibility for Discharge Against Medical Advice (AMA)
UPDATED 2024
Use this form to document that a resident is discharging him- or herself against the medical advice of the attending physician and that the resident has been informed of:
• | the risks and consequences of leaving the facility, |
| • | the benefits of continued skilled or nursing facility care, |
| • | and alternatives if applicable. |
Captures date, time, all applicable signatures, and documents the release of the attending physician, any other physician involved in care, the facility, and its agents or employees from all responsibility for any ill effects which may result from the decision to discharge against medical advice (AMA).
The form also documents if the resident refuses to sign the document.
Size: 8 1/2" x 11"
Paper: white paper, black ink, printed on one side
Punching: 5-hole punched top and side
Packaging: 100/pad