AGAINST MEDICAL ADVICE (AMA) DISCHARGE FORM

[FACILITY NAME]

[FACILITY ADDRESS]

Patient Information:

SECTION 1: PATIENT ACKNOWLEDGMENT

I, [________________________________________], 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 the healthcare team.

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

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

B. Risks of Leaving

☐ I have been informed of the potential risks and consequences of leaving against medical advice, including but not limited to:

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

C. Recommended Treatment Declined

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

D. Voluntary Decision

☐ I understand this decision is voluntary and made of my own free will
☐ I have been given the opportunity to ask questions and have received satisfactory answers
☐ I understand I may return for treatment at any time
☐ I release this facility and its medical staff from liability for consequences arising solely from my decision to leave AMA, to the extent permitted by law

SECTION 2: DISCHARGE INSTRUCTIONS

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

Medications:
☐ Continue 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:

☐ Patient has decision-making capacity (alert, oriented, understands condition and risks, can communicate choice)
☐ Patient's capacity is questionable — steps taken: [________________________________________]
☐ Psychiatric or ethics 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 medical record by: [________________________________________]

Witness Signature

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

Physician Signature

I have explained the risks of leaving AMA, recommended continued treatment, and documented this discussion.

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

SECTION 5: INTERPRETER (IF APPLICABLE)

☐ Interpreter services were used

Language: [________________]
Interpreter Name: [________________________________________]

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

SECTION 6: BELONGINGS

☐ All personal belongings returned to patient
☐ Valuables returned from facility safe
☐ Patient left without collecting belongings

This form is confidential medical information protected under HIPAA (45 C.F.R. Parts 160, 164) and Texas Medical Privacy Act (Tex. Health & Safety Code Ch. 181).