AGAINST MEDICAL ADVICE (AMA) DISCHARGE FORM

[FACILITY NAME]

[FACILITY ADDRESS]

Patient Information:

SECTION 1: PATIENT ACKNOWLEDGMENT

I, [________________________________________], hereby acknowledge and confirm the following:

A. Decision to Leave

☐ I have decided to leave [FACILITY NAME] against the advice of my treating physician(s) and healthcare team.

☐ I understand that my attending physician, Dr. [________________________________________], has recommended that I remain in the hospital for continued treatment of the following condition(s):

Diagnosis / Condition(s):
[________________________________________]
[________________________________________]

B. Risks Explained

☐ I have been informed of the potential risks and consequences of leaving the facility against medical advice, which may include but are not limited to:

• [________________________________________]
• [________________________________________]
• [________________________________________]
• Worsening of my current condition
• Development of complications requiring emergency readmission
• Permanent disability
• Death

C. Recommended Treatment

☐ I have been informed that the following treatment(s) and/or procedure(s) were recommended but will not be completed due to my decision to leave:

[________________________________________]
[________________________________________]

D. Understanding of Rights

☐ I understand that I have the right to leave this facility at any time, pursuant to Cal. Health & Safety Code § 1262
☐ I understand that this decision is voluntary and made of my own free will
☐ I understand that I may return for treatment at any time
☐ I have been given the opportunity to ask questions and have had my questions answered

SECTION 2: DISCHARGE INSTRUCTIONS

Even though you are leaving against medical advice, the following instructions are provided for your safety:

Follow-Up Care:
☐ Follow up with Dr. [________________________________________] within [____] days
☐ Go to the nearest emergency department if: [________________________________________]
☐ Call 911 immediately if: [________________________________________]

Medications:
☐ Continue current medications as prescribed: [________________________________________]
☐ New prescriptions provided: [________________________________________]
☐ No medications prescribed at discharge

Warning Signs — Return Immediately If:
- [________________________________________]
- [________________________________________]
- [________________________________________]

SECTION 3: PATIENT CAPACITY ASSESSMENT

The undersigned physician certifies:

☐ The patient has been assessed and has the capacity to make this decision (oriented, understands risks, can communicate choice, and can appreciate consequences)
☐ The patient's capacity to make this decision is questionable — the following steps were taken: [________________________________________]
☐ Psychiatric consultation obtained: ☐ Yes ☐ No ☐ Not indicated

Assessment Notes:
[________________________________________]

SECTION 4: SIGNATURES

Patient Signature

I have read this form (or had it read to me), understand its contents, and voluntarily choose to leave against medical advice.

Patient Signature: ________________________________________
Printed Name: [________________________________________]
Date: [__/__/____] Time: [____:____] ☐ AM ☐ PM

☐ Patient refused to sign — documented in medical record by: [________________________________________]

Witness Signature

Witness Signature: ________________________________________
Printed Name: [________________________________________]
Title: [________________]
Date: [__/__/____] Time: [____:____] ☐ AM ☐ PM

Physician Signature

I have explained the risks of leaving against medical advice, the recommended treatment, and the potential consequences to the patient.

Physician Signature: ________________________________________
Printed Name: [________________________________________]
License No.: [________________]
Date: [__/__/____] Time: [____:____] ☐ AM ☐ PM

SECTION 5: INTERPRETER (IF APPLICABLE)

☐ Interpreter services were used per Cal. Health & Safety Code § 1259

Language: [________________]
Interpreter Name: [________________________________________]
Interpreter ID/Certification: [________________]

Interpreter Signature: ________________________________________
Date: [__/__/____]

SECTION 6: BELONGINGS AND VALUABLES

☐ All personal belongings returned to patient
☐ Valuables from safe returned to patient
☐ Patient left without collecting belongings — stored per facility policy

This form is confidential medical information protected under the California Confidentiality of Medical Information Act (Cal. Civ. Code § 56 et seq.) and HIPAA (45 C.F.R. Parts 160, 164).