AGAINST MEDICAL ADVICE (AMA) DISCHARGE FORM

[FACILITY NAME]

[FACILITY ADDRESS]

Patient Information:

SECTION 1: PATIENT ACKNOWLEDGMENT

I, [________________________________________], acknowledge and confirm:

A. Decision to Leave

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

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

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

B. Risks Explained

☐ I have been informed of the potential risks and consequences of leaving AMA, which include but are not limited to:

• [________________________________________]
• [________________________________________]
• [________________________________________]
• Worsening of my condition
• Complications requiring emergency readmission
• Permanent disability
• Death

C. Treatment Declined

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

D. Understanding of Rights

☐ I understand my right to refuse treatment under 10 NYCRR § 405.7(a)(6)
☐ This decision is voluntary and of my own free will
☐ I may return for care at any time
☐ I have had the opportunity to ask questions
☐ I have received a copy of the Patient's Bill of Rights per 10 NYCRR § 405.7

SECTION 2: DISCHARGE INSTRUCTIONS

Follow-Up Care:
☐ Follow up with Dr. [________________________________________] within [____] days
☐ Contact your primary care physician: [________________________________________]
☐ Return to the emergency department or call 911 if: [________________________________________]

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

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

Community Resources:
☐ Referral to community health center: [________________________________________]
☐ Social work contact provided: [________________________________________]

SECTION 3: CAPACITY ASSESSMENT

☐ Patient has decision-making capacity (alert, oriented, understands condition and risks, can communicate choice and appreciate consequences)
☐ Patient's capacity is questionable — steps taken: [________________________________________]
☐ Psychiatric consultation obtained: ☐ Yes ☐ No
☐ Ethics committee 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 in record by: [________________________________________]

Witness Signature

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

Physician Signature

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

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

SECTION 5: INTERPRETER (IF APPLICABLE)

☐ Interpreter services provided (per 10 NYCRR § 405.7(a)(7) and, for NYC facilities, Local Law 73)

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

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

SECTION 6: BELONGINGS

☐ All personal belongings returned
☐ Valuables returned from facility safe
☐ Patient departed without collecting belongings

This form contains protected health information under HIPAA (45 C.F.R. Parts 160, 164) and NY Pub. Health Law § 18. Maintain in accordance with facility record retention policies.