Against Medical Advice
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1MARIN COUNTY EMS
AGAINST MEDICAL ADVICE (AMA)–RELEASE AT SCENE (RAS) FORM
CRITERIA FOR REFUSING CARE
The patient meets all of the following:
1. Is an adult (18 or over), or if < 18 meets the criteria stated in the AMA/RAS policy
2. Exhibits no evidence of:
Altered level of consciousness
Alcohol or drug ingestion that impairs judgment
3. Understands the nature of the medical condition, as well as the risks and consequences refusing care
1. ACKNOWLEDGMENT OF INFORMATION:
A. AMA: I have been advised that medical assistance on my behalf is necessary, and that refusal of said assistance could
be hazardous to my health, and under certain circumstances, including disability and/or death. I have been advised to discuss my
medical complaints with my regular health care provider as soon as possible. Nevertheless, I refuse to accept treatment or transport to
a medical facility and assume all risks and consequences of any decision.
or
B. RAS: I acknowledge that I may have a medical problem, which may require additional medical attention, and that an
ambulance is available to transport me to the hospital. Instead, I elect to seek alternative medical care and refuse further treatment
and/or transport.
2. RELEASE OF LIABILITY: By signing this form, I am releasing the County of Marin, the responding Provider Agency(ies), and
the Receiving Hospital (if contacted) of any liability or medical claims resulting from my decision to refuse the medical care/transport
offered.
I have read and understand the “Acknowledgment of Information” and “Release of Liability”. I also
acknowledge that I have received a Notice of Privacy Practices.
Signature: ____________________________________________ Refused to sign, Reason: _____________________________
Relationship (if not the patient): Lawful: parent guardian conservator (pertains to a child/dependent only)
Physician Consulted: _______________________________________________________
Telephone consent/refusal obtained. Witnessed by: ________________________________
Interpreter used: ___________________________________________________________
DISPOSITION:
Instructions
Released in care or custody of self.
1.
If you change your mind or your condition changes, call
9-1-1 (in an emergency), go to an emergency department
Released in custody of law enforcement
Di
in your area, or call your private doctor (if appropriate).
Agency: _________________
2.
________________________________________
Badge #: _________________
________________________________________
Released in care or custody of:
3.
________________________________________
Parent
Guardian
________________________________________
Other: __________________
Completed by (Print)___________________________Signature____________________________ Unit #/Agency #_____________
Witness Information
Signature: _______________________________________ Name Printed: __________________________________________
Address: _____________________________________________________ City: _____________________________________
State: _______ Zip: ________ Phone: (
) _________________ Driver’s License #: ________________________________
Patient Name: _____________________________________________________________ EM/AO#: _________________________
DDM: _________________________________________________________
Date: _____________________________________
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