Get NV Sample Release of Medical Assistance

Nevertheless and understanding all of the above I or my guardian refuse to accept emergency medical care transport to a hospital facility transport to Hospital as directed by Southern Nevada EMS protocols but request assume all risks and consequences resulting from my or my guardian s decision and release Clark County provider agencies and all personnel directly or indirectly involved in my care from any and all liability resulting from my or my guardian s refusal. I have had the opportunity to ask all of the questions I feel necessary to provide this informed refusal. 5. The reason for this refusal is as follows to be completed by patient/guardian Patient s Name DOB Patient s Address Patient s Phone Number Signature Patient/Guardian Witness Date Time Incident Refused to Sign Patient/Guardian Telemetry Physician G EMS Protocols AMA Form Final AMA form.doc Hospital. SAMPLE RELEASE OF MEDICAL ASSISTANCE 1. I or my guardian have been informed of the reason I should go to the hospital for further emergency care. advised that I seek the advice of a physician as soon as possible. or my guardian s refusal to go to the hospital for further emergency care. necessary and that refusal of recommended care and transport to a hospital facility may result in death or imperil my/the patient s health by increasing the opportunity for consequences or complications. Nevertheless and understanding all of the above I or my guardian refuse to accept emergency medical care transport to a hospital facility transport to Hospital as directed by Southern Nevada EMS protocols but request assume all risks and consequences resulting from my or my guardian s decision and release Clark County provider agencies and all personnel directly or indirectly involved in my care from any and all liability resulting from my or my guardian s refusal* I have had the opportunity to ask all of the questions I feel necessary to provide this informed refusal* 5. The reason for this refusal is as follows to be completed by patient/guardian Patient s Name DOB Patient s Address Patient s Phone Number Signature Patient/Guardian Witness Date Time Incident Refused to Sign Patient/Guardian Telemetry Physician G EMS Protocols AMA Form Final AMA form*doc Hospital. SAMPLE RELEASE OF MEDICAL ASSISTANCE 1. I or my guardian have been informed of the reason I should go to the hospital for further emergency care. advised that I seek the advice of a physician as soon as possible. or my guardian s refusal to go to the hospital for further emergency care. advised that I seek the advice of a physician as soon as possible. or my guardian s refusal to go to the hospital for further emergency care. necessary and that refusal of recommended care and transport to a hospital facility may result in death or imperil my/the patient s health by increasing the opportunity for consequences or complications. necessary and that refusal of recommended care and transport to a hospital facility may result in death or imperil my/the patient s health by increasing the opportunity for consequences or complications. Nevertheless and understanding all of the above I or my guardian refuse to accept emergency medical care transport to a hospital facility transport to Hospital as directed by Southern Nevada EMS protocols but request assume all risks and consequences resulting from my or my guardian s decision and release Clark County provider agencies and all personnel directly or indirectly involved in my care from any and all liability resulting from my or my guardian s refusal* I have had the opportunity to ask all of the questions I feel necessary to provide this informed refusal* 5. .