Get Mi Sample Ems Refusal Form 2017-2025

The MI Sample EMS Refusal Form is an essential document for individuals choosing to refuse medical evaluation, treatment, or transport. This guide provides straightforward instructions on how to accurately complete this form online, ensuring that your choices are clearly documented and respected.

Follow the steps to fill out the form correctly online.

1. Press the ‘Get Form’ button to obtain the MI Sample EMS Refusal Form and open it in the online editor.
2. Begin by reading the form thoroughly. It explains the implications of refusing care, emphasizing the importance of being evaluated by medical personnel.
3. In the section labeled 'I refuse,' circle the options that apply to your situation: Evaluation, Treatment, or Transport. Ensure that your decisions are clearly indicated.
4. For the patient’s details, fill in the following fields: Printed Name, Age, Date of Birth, and Phone Number.
5. Complete the Patient’s Address section, including City, State, and Zip code.
6. Sign the form in the 'Signature' section. If applicable, include your relationship to the patient.
7. A witness must also sign the form. They should then print their name in the designated area.
8. Document the Date and Time the form is filled out.
9. Record relevant medical information such as Blood Pressure, Pulse, Respiratory rate, Skin condition, Pupils response, and Level of Consciousness (LOC) in the appropriate fields.
10. Answer the questions regarding the patient’s mental state, circling 'Yes' or 'No' as applicable.
11. In the Narrative section, describe reasonable alternatives to treatment that were discussed, the circumstances of the call, and any relevant consequences of the refusal.
12. Ensure that the EMS Agency Name and Printed Crew Names sections are completed.
13. Lastly, if required, add the MCA Implementation Date, Signature of the EMS Provider, MCA Name, and MCA Board Approval Date. Review all entries for accuracy before submitting.
14. Once completed, you can save the changes, download the form, print it, or share it as needed.

Complete your MI Sample EMS Refusal Form online today!