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RELEASE AGAINST MEDICAL ADVICE

MEDICAL RECORD

For use of this form, see AR 40-68; proponent agency is the Office of The Surgeon General.

STATEMENT OF PATIENT RELEASING HOSPITAL/CLINIC FROM LIABILITY

UPON LEAVING HOSPITAL/CLINIC AGAINST MEDICAL ADVICE

1. This is to certify that I am leaving

at my own insistence and against the advice of the

(Name of Medical Treatment Facility)

hospital/clinic authorities and my attending physician(s).

2. I have been advised of and understand the potential dangers involved in leaving the hospital/clinic at this time. The potential medical

risks that have been explained to me include:

3. I have been advised of and understand the follow-up actions recommended by my health care provider which include:

4. I hereby release the hospital/clinic, its staff and the Federal Government of all responsibility for any ill effects brought about by my

failure to continue medical evaluation and/or treatment as recommended.

(Signature of Patient/Date and Time)

(Signature of Physician/Designee)

(Signature and Address of Witness)

STATEMENT OF REPRESENTATIVE OF PATIENT RELEASING

HOSPITAL/CLINIC FROM LIABILITY UPON LEAVING HOSPITAL/CLINIC AGAINST MEDICAL ADVICE

1. Representative's name

Relationship to the patient

2. I,

, insist that

be discharged/released from

(Patient's Name)

(Representative's Name)

without the authorization of hospital/clinic authorities and his/her attending physician(s).

(Name of Medical Treatment Facility)

3. I have been advised of and understand the potential dangers involved in having the patient leave the hospital/clinic at this time. The

potential medical risks that have been explained to me include:

4. I have been advised of and understand the follow-up actions recommended for the patient which include:

5. I hereby release the hospital/clinic, its staff and the Federal Government of all responsibility for any ill effects associated with failure

to continue

's medical evaluation and/or treatment as recommended.

(Patient's Name)

(Signature of Patient's Representative/Date and Time)

(Signature of Physician/Designee)

(Signature and Address of Witness)

PREPARED BY (Signature and Title)

Patient ID Plate or Printed Name and SSN,

Address, and Daytime Telephone Number

DEPARTMENT/WARD/CLINIC

DATE (YYYYMMDD)

TIME

PREVIOUS EDITIONS ARE OBSOLETE.

APD LC v1.01ES

DA FORM 5009, FEB 2004

Release Against Medical Advice

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