Against Medical Advice (AMA) Discharge Form

LEAVING AGAINST MEDICAL ADVICE (AMA)

Refusal of Recommended Treatment / Discharge Against Medical Advice

Facility Name: [________________________________]

Facility Address: [________________________________]

Facility Phone: [________________________________]

PATIENT INFORMATION

SECTION 1: TYPE OF DISCHARGE OR REFUSAL

Select the applicable category:

☐ Leaving Against Medical Advice (AMA) — Patient wishes to leave the facility before the recommended course of treatment is complete

☐ Refusal of Recommended Treatment — Patient wishes to refuse specific recommended treatment(s) while remaining in the facility

☐ Refusal of Recommended Admission — Patient in the emergency department or outpatient setting refuses recommended inpatient admission

☐ Elopement / Left Without Being Seen (LWBS) — Patient left without informing staff or before evaluation was completed (complete Section 11)

☐ Refusal of Recommended Transfer — Patient refuses recommended transfer to a higher level of care or specialized facility

1.1 EMTALA Applicability

☐ EMTALA applies — Patient presented to the Emergency Department with an emergency medical condition

• ☐ Emergency medical condition has been stabilized prior to AMA request
• ☐ Emergency medical condition has NOT been stabilized — EMTALA informed refusal documentation required (see Section 1.2)

☐ EMTALA does not apply — Patient is an inpatient or did not present with an emergency medical condition

1.2 EMTALA Informed Refusal (Complete if Emergency Condition Not Stabilized)

Per 42 U.S.C. § 1395dd(b)(2), the patient has been informed of the hospital's obligation to provide stabilizing treatment, the risks and benefits of the proposed examination and treatment, and the risks of refusal:

☐ Patient informed of hospital's EMTALA obligation to provide stabilizing treatment

☐ Patient informed of risks and benefits of proposed stabilizing treatment

☐ Written informed refusal obtained (attach documentation)

☐ Patient refused to sign informed refusal documentation — witnessed verbal refusal documented below

SECTION 2: PATIENT'S STATED REASON FOR LEAVING OR REFUSING TREATMENT

Patient's stated reason (document in the patient's own words):

[________________________________]

[________________________________]

[________________________________]

Additional reasons identified (check all that apply):

☐ Personal or family obligations

☐ Work or employment obligations

☐ Financial concerns or lack of insurance

☐ Disagrees with diagnosis or treatment plan

☐ Desires second opinion

☐ Religious or cultural reasons

☐ Discomfort with care, staff, or facility environment

☐ Substance use, craving, or withdrawal

☐ Psychiatric or behavioral health reasons

☐ Childcare or dependent care obligations

☐ Transportation issues

☐ No reason given or patient declined to state reason

☐ Other: [________________________________]

SECTION 3: CLINICAL INFORMATION

3.1 Diagnosis and Current Condition

Admitting or Working Diagnosis: [________________________________]

ICD-10 Code(s): [________________________________]

Current Clinical Status: [________________________________]

[________________________________]

Vital Signs at Time of AMA Request:

3.2 Treatment Provided During This Encounter

Summary of treatment, medications, and procedures already provided:

[________________________________]

[________________________________]

[________________________________]

3.3 Recommended Treatment Being Refused

Specific treatment, procedures, or continued care the patient is refusing:

[________________________________]

[________________________________]

[________________________________]

3.4 Treating Physician and Care Team

SECTION 4: RISKS EXPLAINED TO PATIENT

The following risks of leaving against medical advice or refusing the recommended treatment have been explained to the patient in clear, understandable language:

4.1 General Risks of Leaving AMA or Refusing Treatment

☐ Worsening of current condition

☐ Development of additional or unforeseen complications

☐ Need for emergency medical treatment in the future

☐ Need for more extensive, invasive, or costly treatment later

☐ Prolonged illness or delayed recovery

☐ Permanent injury or disability

☐ Death

4.2 Condition-Specific Risks

The following specific risks related to the patient's particular diagnosis and clinical condition have been explained:

☐ [________________________________]

☐ [________________________________]

☐ [________________________________]

☐ [________________________________]

☐ [________________________________]

Additional condition-specific risk explanation:

[________________________________]

4.3 Clinical Risk Level Assessment

Without the recommended treatment, the patient's risk of serious adverse outcome is assessed as:

☐ Low — Condition is unlikely to cause significant harm in the near term, but follow-up is recommended

☐ Moderate — Condition poses a meaningful risk of worsening, complications, or need for emergency treatment

☐ High — Condition poses a significant risk of serious harm, permanent disability, or death

☐ Imminent / Life-Threatening — Condition poses an immediate risk of death or irreversible harm without continued treatment

4.4 Patient's Demonstrated Understanding

☐ Patient verbalized understanding of the diagnosis and risks in their own words

☐ Patient asked questions, which were answered by the physician

☐ Patient demonstrated understanding by restating key risks: [________________________________]

☐ Patient appeared to understand despite limited verbalization

☐ Interpreter services were used — Language: [________________________________]

☐ Concerns about patient's level of understanding exist: [________________________________]

SECTION 5: ALTERNATIVE OPTIONS OFFERED

The following alternatives to full AMA discharge were offered to the patient:

☐ Transfer to another facility or level of care

☐ Modified or partial treatment plan: [________________________________]

☐ Extended observation period before final decision

☐ Outpatient treatment with close follow-up within [____] hours/days

☐ Home health services or visiting nurse referral

☐ Referral to specialist: [________________________________]

☐ Contact with family member or support person to discuss the decision

☐ Social work consultation

☐ Psychiatric or behavioral health consultation (if capacity concerns exist)

☐ Ethics committee consultation

☐ Chaplain or spiritual care consultation

☐ Case management consultation for financial or insurance concerns

☐ Patient advocate consultation

☐ Other: [________________________________]

Patient's response to alternatives offered:

[________________________________]

[________________________________]

SECTION 6: DECISION-MAKING CAPACITY ASSESSMENT

6.1 Capacity Determination

The patient has been assessed for medical decision-making capacity by the treating physician:

☐ Patient HAS decision-making capacity — Patient demonstrates all four abilities (communicating a choice, understanding, appreciation, and reasoning)

☐ Patient's capacity is QUESTIONABLE — Proceed to Section 6.4

☐ Patient LACKS decision-making capacity — Do NOT proceed with AMA discharge; proceed to Section 6.4

6.2 Appelbaum Four-Abilities Capacity Assessment

6.3 Factors Potentially Affecting Capacity

☐ No factors affecting capacity identified

☐ Alcohol intoxication (BAC if available: [____])

☐ Illicit substance intoxication (substance: [________________________________])

☐ Substance withdrawal

☐ Acute psychiatric condition (specify: [________________________________])

☐ Dementia or cognitive impairment

☐ Delirium or acute confusional state

☐ Medication effects (specify: [________________________________])

☐ Severe pain affecting cognition

☐ Metabolic disturbance (specify: [________________________________])

☐ Traumatic brain injury or neurological condition

☐ Developmental or intellectual disability

☐ Language barrier (interpreter used: ☐ Yes ☐ No)

☐ Other: [________________________________]

6.4 Actions Taken When Capacity is Questionable or Absent

☐ Psychiatric consultation requested — Date/Time: [________________________________]

☐ Ethics committee consultation requested — Date/Time: [________________________________]

☐ Decision delayed pending formal capacity evaluation

☐ Legal counsel or risk management consulted — Date/Time: [________________________________]

☐ Surrogate decision-maker or healthcare proxy contacted: [________________________________]

☐ Patient retained despite AMA request due to imminent safety concerns

☐ Involuntary hold initiated per applicable state law (specify statute: [________________________________])

☐ Other: [________________________________]

SECTION 7: DISCHARGE INSTRUCTIONS PROVIDED

Despite leaving against medical advice, the following discharge instructions and resources have been provided to the patient:

7.1 Warning Signs Requiring Immediate Emergency Care

The patient has been instructed to call 911 or return immediately to the nearest emergency department if they experience:

☐ [________________________________]

☐ [________________________________]

☐ [________________________________]

☐ [________________________________]

☐ Worsening of current symptoms

☐ New or unexpected symptoms

☐ Fever above [____] degrees

☐ Difficulty breathing or shortness of breath

☐ Chest pain or pressure

☐ Uncontrolled bleeding

☐ Change in mental status, confusion, or loss of consciousness

☐ Severe or worsening pain

☐ Other: [________________________________]

7.2 Medications

☐ Prescription(s) provided for immediately necessary medications: [________________________________]

☐ Instructions for current home medications reviewed and provided

☐ Patient declined prescription(s)

☐ No prescriptions provided — clinical rationale: [________________________________]

7.3 Follow-Up Care

☐ Follow up with primary care physician: Dr. [________________________________] within [____] days

☐ Follow up with specialist: [________________________________] within [____] days

☐ Return to this facility if symptoms worsen or new concerns arise

☐ Follow-up appointment scheduled: [________________________________] on [__/__/____] at [____]

☐ Referrals provided: [________________________________]

☐ Home health or visiting nurse referral initiated

☐ Patient declined all follow-up arrangements

7.4 Additional Discharge Instructions

[________________________________]

[________________________________]

7.5 Delivery of Instructions

☐ Written discharge instructions provided to patient

☐ Instructions explained verbally to patient

☐ Written and verbal instructions provided to patient's family/support person: [________________________________]

☐ Instructions provided in patient's preferred language: [________________________________]

☐ Patient refused to accept written discharge instructions

☐ Discharge instructions placed in patient's belongings

SECTION 8: PATIENT ACKNOWLEDGMENTS AND INFORMED REFUSAL

By signing below, I, the undersigned patient (or authorized representative), acknowledge and confirm the following:

☐ I understand that my physician(s) recommend that I [________________________________] (e.g., remain hospitalized for continued treatment, undergo the recommended procedure, accept admission for further evaluation)

☐ I understand the nature of my illness, injury, or medical condition as it has been explained to me

☐ I understand the risks of leaving against medical advice or refusing the recommended treatment, including but not limited to the possibility of worsening of my condition, complications, the need for more extensive treatment in the future, permanent disability, or death

☐ I have been informed of the specific risks related to my particular condition as described in Section 4 above

☐ I have been informed of and offered alternative treatment options

☐ I have had the opportunity to ask questions, and my questions have been answered to my satisfaction

☐ I am making this decision voluntarily, of my own free will, and without coercion

☐ I accept full responsibility for the consequences that may result from my decision to leave against medical advice or refuse the recommended treatment

☐ I release and discharge [________________________________] (facility name), its physicians, nurses, employees, and agents from any and all liability and responsibility for any adverse consequences or injury that may result from my refusal of the recommended treatment or my decision to leave against medical advice

☐ I understand that I may return for treatment at any time and that seeking timely medical care remains important

☐ I have received discharge instructions, including warning signs that should prompt me to seek immediate emergency medical care

☐ I understand that my insurance may not cover costs associated with readmission for the same or related condition

SECTION 9: SIGNATURES

9.1 Patient or Authorized Representative

Signature: ______________________________________

Printed Name: [________________________________]

Relationship to Patient (if representative): [________________________________]

Date: [__/__/____]

Time: [____]

9.2 If Patient Refuses to Sign

☐ Patient refused to sign this form

The risks of leaving against medical advice and the contents of this form were fully explained to the patient. The patient verbally acknowledged understanding of the risks but declined to sign this document. The patient's verbal statements and refusal to sign have been witnessed as documented below.

Witness to Patient's Verbal Acknowledgment and Refusal to Sign:

9.3 Treating Physician Attestation

I, the undersigned physician, attest that I have personally:

☐ Assessed the patient's decision-making capacity

☐ Explained the patient's diagnosis, current clinical status, and prognosis

☐ Explained the recommended treatment plan and its expected benefits

☐ Explained the specific risks of leaving against medical advice or refusing treatment, including the risk of serious harm or death

☐ Offered reasonable alternatives to full AMA discharge

☐ Answered the patient's questions

☐ Made reasonable efforts to encourage the patient to remain for recommended treatment

☐ Provided discharge instructions, prescriptions, and follow-up recommendations

Physician Signature: ______________________________________

Printed Name and Credentials: [________________________________]

Date: [__/__/____]

Time: [____]

9.4 Nursing Witness

Witness Signature: ______________________________________

Printed Name: [________________________________]

Title: [________________________________]

Date: [__/__/____]

Time: [____]

9.5 Interpreter (If Used)

☐ Interpreter services were used for this encounter

Interpreter Signature: ______________________________________

Printed Name: [________________________________]

Language Interpreted: [________________________________]

Interpretation Method: ☐ In-person ☐ Telephone ☐ Video

Date: [__/__/____]

SECTION 10: INSURANCE AND BILLING NOTIFICATION

☐ Patient informed that leaving AMA may affect insurance coverage for this visit or related readmissions

☐ Patient informed that the facility will submit claims for services already rendered

☐ Patient referred to financial counseling or patient financial services

☐ Insurance notification not applicable or not provided

Note to Facility Staff: Medicare and most insurers do NOT automatically deny payment for AMA discharges. Do not represent to patients that their insurance will deny the claim solely because of AMA status.

SECTION 11: ELOPEMENT — PATIENT LEFT WITHOUT COMPLETING AMA PROCESS

☐ Patient left before AMA form could be completed

☐ Patient eloped from the unit or facility without informing staff

☐ Patient left the emergency department without being seen (LWBS)

☐ Patient left during diagnostic workup before results were available

Time patient was last seen by staff: [____]

Time patient was discovered to have left: [____]

Location last seen: [________________________________]

Circumstances of departure:

[________________________________]

[________________________________]

11.1 Efforts to Contact Patient After Departure

11.2 If Patient Was Reached

☐ Risks of leaving were explained by phone

☐ Patient declined to return to the facility

☐ Patient agreed to return to the facility

☐ Patient agreed to follow up with primary care or other provider

☐ Patient was non-responsive or unable to communicate

11.3 Welfare Check or Law Enforcement Notification

☐ Not clinically indicated

☐ Welfare check requested — Reason: [________________________________]

☐ Law enforcement notified — Reason: [________________________________]

☐ Psychiatric emergency team or crisis services notified — Reason: [________________________________]

11.4 Pending Test Results or Critical Findings

☐ No pending tests or results

☐ Pending test results exist — Plan for notification: [________________________________]

☐ Critical findings resulted after departure — Actions taken: [________________________________]

Elopement documented by: [________________________________] Title: [________________________________]

Date: [__/__/____] Time: [____]

SECTION 12: ADDITIONAL DOCUMENTATION

Additional notes regarding the AMA discussion, circumstances, and clinical judgment:

[________________________________]

[________________________________]

[________________________________]

[________________________________]

SECTION 13: CONTACT INFORMATION FOR PATIENT

If you change your mind or your condition worsens:

Emergency: Call 911 or go to the nearest emergency room immediately

Return to this facility:

• Facility Name: [________________________________]
• Address: [________________________________]
• Main Phone: [________________________________]
• Emergency Department: [________________________________]

Your Primary Care Physician:

• Name: [________________________________]
• Phone: [________________________________]

24-Hour Nurse Hotline (if available): [________________________________]

Crisis/Mental Health Hotline: 988 Suicide and Crisis Lifeline (call or text 988)

SECTION 14: MEDICAL RECORD AND COMPLIANCE NOTES

For facility use only:

Record Retention: This form must be maintained as part of the permanent medical record in accordance with applicable state medical records retention laws, HIPAA regulations (45 CFR Part 164), and facility policy. Most states require retention of medical records for a minimum of 5-10 years from the date of last treatment (longer for minors).

Sources and References

1. 42 CFR § 482.13 — Condition of Participation: Patient's Rights
   CMS regulation establishing patient rights in Medicare-participating hospitals, including the right to make informed decisions and to refuse treatment.
   https://www.law.cornell.edu/cfr/text/42/482.13

2. 42 U.S.C. § 1395dd — Emergency Medical Treatment and Active Labor Act (EMTALA)
   Federal statute requiring hospitals with emergency departments to provide screening examinations and stabilizing treatment regardless of ability to pay, including requirements for informed refusal when patients decline stabilization.
   https://www.law.cornell.edu/uscode/text/42/1395dd

3. 42 CFR § 482.43 — Condition of Participation: Discharge Planning
   CMS regulation requiring hospitals to have an effective discharge planning process, applicable even when patients leave AMA.
   https://www.law.cornell.edu/cfr/text/42/482.43

4. 45 CFR Part 164 — HIPAA Privacy and Security Standards
   Federal regulations governing the privacy and security of protected health information (PHI), including medical records retention and patient access rights.
   https://www.law.cornell.edu/cfr/text/45/part-164

5. Joint Commission Hospital Accreditation Standards — Rights and Responsibilities of the Individual (RI)
   Accreditation standards addressing patient rights, informed consent, and informed refusal in hospital settings.
   https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/rights-and-responsibilities-of-the-individual-ri/

6. Appelbaum PS, Grisso T — Assessing Patients' Capacities to Consent to Treatment (1988)
   The foundational four-abilities model for medical decision-making capacity assessment: communicating a choice, understanding, appreciation, and reasoning.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC10922513/

7. ACEP — Understanding EMTALA
   American College of Emergency Physicians resource on EMTALA compliance, including obligations when patients refuse stabilizing treatment.
   https://www.acep.org/life-as-a-physician/ethics--legal/emtala/emtala-fact-sheet

8. CMS Hospital Readmissions Reduction Program (HRRP)
   Medicare value-based purchasing program that penalizes hospitals for excessive 30-day readmissions; relevant context for AMA discharge follow-up protocols.
   https://www.cms.gov/medicare/quality/value-based-programs/hospital-readmissions-reduction

9. AMA Journal of Ethics — Defining Hospitals' Obligation to Stabilize Patients Under EMTALA
   Analysis of hospital obligations under EMTALA, including stabilization requirements and patient refusal scenarios.
   https://journalofethics.ama-assn.org/article/defining-hospitals-obligation-stabilize-patients-under-emtala/2006-11

10. AAFP — Evaluating Medical Decision-Making Capacity in Practice
    Practical guidance on applying the Appelbaum capacity assessment framework in clinical settings, including AMA scenarios.
    https://www.aafp.org/pubs/afp/issues/2018/0701/p40.html

This template is provided for informational and educational purposes only. It does not constitute legal or medical advice. Each healthcare facility must customize this form to comply with applicable federal and state laws, institutional policies, and accreditation requirements. Qualified healthcare legal counsel and clinical leadership should review and approve this form before implementation.