AGAINST MEDICAL ADVICE (AMA) DISCHARGE FORM

[FACILITY NAME]

[FACILITY ADDRESS]

Patient Information:

SECTION 1: PATIENT ACKNOWLEDGMENT

I, [________________________________________], acknowledge the following:

A. Decision to Leave

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

☐ My attending physician, Dr. [________________________________________], has recommended I remain hospitalized for treatment of:

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

B. Risks of Leaving

☐ The following risks and potential consequences of leaving AMA have been explained to me:

• [________________________________________]
• [________________________________________]
• [________________________________________]
• Worsening of my medical condition
• Need for emergency readmission
• Permanent disability or impairment
• Death

C. Treatment Declined

☐ The following recommended treatment(s) will not be completed:
[________________________________________]
[________________________________________]

D. Patient Rights and Understanding

☐ I understand my right to refuse treatment under Fla. Stat. § 381.026(4)(c)
☐ I am making this decision voluntarily and of my own free will
☐ I have had the opportunity to ask questions and my questions have been answered
☐ I understand I may return for care at any time
☐ I have received a copy of the Florida Patient's Bill of Rights and Responsibilities

SECTION 2: DISCHARGE PLANNING

Pursuant to Fla. Stat. § 395.0142, the following discharge instructions are provided:

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

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

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

SECTION 3: CAPACITY ASSESSMENT

☐ Patient has been assessed and has decision-making capacity
☐ Patient's capacity is questionable — further evaluation taken: [________________________________________]
☐ Psychiatric consultation obtained: ☐ Yes ☐ No

SECTION 4: SIGNATURES

Patient Signature

I have read and understand this form. I voluntarily choose to leave against medical advice.

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

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

Witness Signature

Witness Signature: ________________________________________
Printed Name: [________________________________________]
Title: [________________]
Date: [__/__/____]

Physician Signature

I have informed the patient of the risks of leaving AMA and recommended continued treatment.

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

SECTION 5: INTERPRETER (IF APPLICABLE)

☐ Interpreter services were provided

Language: [________________]
Interpreter Name: [________________________________________]

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

SECTION 6: BELONGINGS

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

This form is confidential medical information protected under HIPAA (45 C.F.R. Parts 160, 164) and Florida law.