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Discharge Against Medical Advice


Discharge Against Medical Advice
Discharge Against Medical Advice
This is to certify that I am leaving Rush University Medical Center at my own insistence and against the advice of my
physicians and the Medical Center. I have been advised of the possible dangers to my life or health from this departure,
and I hereby assume the risks and consequences involved and release my physicians and the Medical Center from any
liability in connection with my leaving the Medical Center against their advice.
DATE: ________________________________ ______________________________________________________
Signature of Party Leaving Against Medical Advice
TIME: ________________________ A.M. / P.M.
WITNESS: IF PARTY DEMANDING DISCHARGE IS OTHER THAN PATIENT:
______________________________________ ______________________________________________________
Signature of Witness Signature of Party
______________________________________________________
Relationship
INSTRUCTIONS: This demand for discharge should be signed by the patient or authorized party if he/she insists on
leaving the Medical Center against medical advice. If the patient or authorized party not only demands
to leave but also refuses to sign this form the following should be completed.
_____________________________________________________ has not only demanded discharge
(Name of Party Demanding Discharge)
but also has refused to sign this form documenting his/her demand.
DATE: ____________________________
TIME: ____________________ A.M. / P.M.
______________________________________________________
Signature of Person Receiving Demand
M/R FORM NO. 1932 (03-15-09)
DISCHARGE AGAINST MEDICAL ADVICE
RUSH UNIVERSITY MEDICAL CENTER
Patient Name: ____________________________________
Date of Birth: _____________________________________
Medical Record #: _________________________________
Place Patient Label
Discharge Against Medical Advice