Florida Against Medical Advice (AMA) Discharge Form

PATIENT-INITIATED DEPARTURE / REFUSAL OF RECOMMENDED CARE RECORD

(Florida)

1. Facility and Care-Setting Gate

Facility / Practice: [NAME AND ADDRESS]

Department / Unit: [DETAILS]

Care setting:

• ☐ Hospital inpatient
• ☐ Hospital emergency department
• ☐ Hospital outpatient department
• ☐ Ambulatory surgical center
• ☐ Physician or practitioner office
• ☐ Behavioral-health setting
• ☐ Other: [DETAILS]

Facility policy and version: [TITLE / VERSION / DATE]

Before using this record, identify any separate emergency-stabilization, involuntary-examination or treatment, custody, isolation, public-health, correctional, minor-consent, surrogate, guardianship, advance-directive, or other rule that affects the person's authority or ability to leave or refuse care: [AUTHORITY / NONE IDENTIFIED].

2. Patient and Encounter

3. Patient's Stated Decision

The patient or authorized representative states:

• ☐ I want to leave before the recommended evaluation or treatment is complete.
• ☐ I refuse only the following test, treatment, transfer, observation, admission, procedure, medication, or follow-up step: [DETAILS].
• ☐ I accept these parts of the plan: [DETAILS].
• ☐ My reason, in my own words: [STATEMENT].
• ☐ Other: [DETAILS].

Do not use the label “AMA” as a substitute for recording the exact decision and the care that remains accepted.

4. Information Provided for the Decision

Fla. Stat. § 381.026(4)(b)3.-4. addresses information about diagnosis, planned treatment, alternatives, risks, and prognosis and documents treatment refusal. Record the patient-specific discussion rather than relying on a generic risk list.

5. Communication and Understanding

• ☐ Discussion occurred directly with the patient.
• ☐ Discussion occurred with the authorized representative identified in Section 2.
• ☐ Qualified interpreter used: [NAME / ID / LANGUAGE / MODE].
• ☐ Communication aid or accommodation used: [DETAILS].
• ☐ Written or translated instructions provided: [DETAILS].
• ☐ Teach-back used; patient or representative explained the decision and principal risks in these words: [DETAILS].
• ☐ Patient declined information after the following offer: [DETAILS].

6. Decision-Making Capacity and Authority Record

This form does not create or prove capacity. The responsible clinician records the assessment relevant to this decision:

• ability to communicate a stable choice: [FINDINGS];
• understanding of relevant information: [FINDINGS];
• appreciation of the situation and likely consequences: [FINDINGS];
• reasoning about options: [FINDINGS]; and
• effects of pain, medication, intoxication, delirium, psychiatric symptoms, cognitive impairment, language, or other barriers: [FINDINGS].

Conclusion and action:

• ☐ Patient appears to have capacity for this specific decision.
• ☐ Capacity is uncertain; consultation / reassessment / delay: [DETAILS].
• ☐ Patient does not appear to have capacity; representative and authority: [DETAILS].
• ☐ Separate legal or clinical authority affects departure or refusal: [DETAILS].
• ☐ Security, ethics, psychiatry, administration, risk, child-protection, or legal counsel consulted: [NAME / TIME / ADVICE].

7. Safer Departure and Continuing Care

Complete the clinically appropriate items even when the patient declines the recommended plan:

• ☐ Immediate treatment accepted before departure: [DETAILS].
• ☐ Medications reconciled; prescriptions or supply: [DETAILS].
• ☐ Follow-up practitioner / clinic / appointment: [DETAILS].
• ☐ Pending test or imaging results and notification plan: [DETAILS].
• ☐ Warning signs and exact response instructions: [DETAILS].
• ☐ Transportation and destination: [DETAILS].
• ☐ Equipment, oxygen, wound care, diet, activity, or other instructions: [DETAILS].
• ☐ Contact information verified: [DETAILS].
• ☐ Caregiver or support person included with permission: [DETAILS].
• ☐ Transfer or referral offered: [DETAILS].
• ☐ Patient declined part or all of this safer plan: [DETAILS].

For a hospital governed by 42 C.F.R. § 482.43, coordinate this record with the hospital's applicable discharge-planning process and transmission of necessary medical information. This template does not decide that every patient or setting triggers every subsection of that rule.

8. Departure Event

• ☐ Patient left after discussion and receipt of instructions.
• ☐ Patient left before discussion could be completed.
• ☐ Patient left without notifying staff; last known time and condition: [DETAILS].
• ☐ Patient remained and accepted the revised plan: [DETAILS].
• ☐ Patient was transferred or referred: [DETAILS].
• ☐ Other: [DETAILS].

Condition at departure or last observation, including vital signs when obtained: [DETAILS].

Lines, devices, medication access, belongings, and valuables addressed: [DETAILS].

Persons notified and time: [ATTENDING / REPRESENTATIVE / CAREGIVER / ADMINISTRATION / OTHER].

9. Patient or Representative Acknowledgment

I received the information recorded above to the extent I chose to receive it. My signature acknowledges the discussion and my stated decision; it is not a release of claims or a statement that every consequence can be predicted.

Signature: ________________________________________

Name and capacity: [________________________________]

Date and time: [________________________________]

• ☐ Patient or representative declined or was unable to sign.
• ☐ Reason / words used: [DETAILS].

A refusal or inability to sign does not replace the clinical documentation above.

10. Clinician and Witness Record

Responsible Clinician

Signature: ________________________________________

Name, credentials, and license number: [________________________________]

Date and time: [________________________________]

Additional Clinician / Nurse / Witness

Signature: ________________________________________

Name and role: [________________________________]

Date and time: [________________________________]

Interpreter, if used

Name / ID / service: [________________________________]

Signature or service record: [________________________________]

Date and time: [________________________________]

11. Record Completion and Review

• ☐ Order and medication record updated.
• ☐ Departure / discharge status entered accurately.
• ☐ Instructions and declined items attached or linked.
• ☐ Required incident, quality, utilization, risk, or supervisor review initiated.
• ☐ Privacy and release-of-information handling completed under facility policy and applicable law.
• ☐ Other: [DETAILS].

Sources and References

• Florida Legislature — 2026 Fla. Stat. § 381.026
• eCFR — 42 C.F.R. § 482.13
• eCFR — 42 C.F.R. § 482.43