Refusal of Care Against Medical Advice
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Refusal of Care Against Medical Advice
Criteria for refusing care
The patient meets all of the following:
1. Is a patient over the age of 18 yrs.
2. Exhibits no evidence of:
 Altered level of consciousness
 Alcohol or drug ingestion that would impair judgment
3. Understands the nature of the medical condition, as well as the risks and consequences of
refusing care.

1. Acknowledgement of Information (Initial on line)
a. ____I have been advised that medical care on my behalf is necessary, and that
refusal of care and assistance could be hazardous to my health, and under
certain circumstances, including disability or death.
OR
b. ____I acknowledge that I may have a medical problem which may require
additional medical attention, and that NDSP or an ambulance is available to
transport me to the hospital. Instead, I elect to seek alternative medical care
and/or refuse further evaluation, treatment and/or transport.
2. Release of Liability (initial on line)
____ By signing this form, I am