California Against Medical Advice (AMA) Discharge Form

AGAINST MEDICAL ADVICE (AMA) DISCHARGE FORM

[GENERAL ACUTE CARE HOSPITAL NAME]

[HOSPITAL ADDRESS]

Scope gate: Use only for a patient in a California general acute care hospital after confirming that the patient may make and act on this decision. Do not use this form as authority to release a minor, a patient who lacks decision-making capacity, or a person subject to a lawful hold, custody, or other restriction. Follow the governing patient-status law and hospital policy.

Patient Information:

SECTION 1: PATIENT ACKNOWLEDGMENT

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

A. Decision to Leave

☐ I have decided to leave [HOSPITAL NAME] against the advice of my treating clinician(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 Cal. Code Regs., tit. 22, § 70707(b)(10) identifies a hospital patient's right to leave even against medical-staff advice.
☐ Hospital staff confirmed that no capacity, minor-status, surrogate-authority, lawful-hold, custody, or other restriction prevents me from acting on this decision.
☐ I understand the follow-up and emergency-care instructions provided below.
☐ 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: DECISION-MAKING CAPACITY AND STATUS CHECK

The treating clinician records the clinical assessment below. Signing this form does not itself establish legal capacity or discharge authority.

☐ The patient can communicate a choice and demonstrates understanding, appreciation, and reasoning concerning the decision and its consequences.
☐ Capacity is uncertain or impaired — the following assessment, consultation, surrogate, or protective steps were taken: [________________________________________]
☐ The patient is a minor or may be subject to a hold, custody, conservatorship, surrogate decision, or other legal restriction — status and authority were confirmed here: [________________________________________]
☐ Consultation obtained: ☐ Psychiatry ☐ Ethics ☐ Risk management ☐ Legal counsel ☐ Other: [________________________________________]

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

Treating Clinician Signature

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

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

SECTION 5: INTERPRETER (IF APPLICABLE)

☐ The hospital offered language-assistance services under its Cal. Health & Safety Code § 1259(c)(2) policy.

☐ Hospital interpreter used

☐ After being informed of available interpreter services, the patient chose a volunteering family member or friend, if permitted by hospital policy and applicable law.

☐ No language or communication barrier was identified.

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

Store, use, and disclose this form under the hospital's record-confidentiality policies and all privacy laws applicable to the hospital and patient. This template does not determine CMIA or HIPAA coverage for a particular organization or disclosure.