Healthcare AMA IPA Form

HEALTHCARE AMA IPA FORM

Patient Name:    DOB:    Medical Record No.:

IPA/Managed Care Affiliation:    Treating Provider:    Encounter Date:

Patient Information

Insurance Information

Medical History (relevant)

Recommended Care and Provider Discussion

Description of recommended treatment, intervention, or admission:

Provider who discussed treatment:    Title:    Date of discussion:

The provider has explained the nature of the diagnosis and the recommended treatment, the expected benefits, foreseeable risks and complications, and reasonable alternatives, including the option to transfer care. The patient has had an opportunity to ask questions and has been provided with answers the provider considers adequate.

Patient Refusal and Acknowledgement (Against Medical Advice)

I voluntarily refuse the recommended treatment, intervention, or admission described above. I understand that by refusing this care I may be increasing the likelihood of serious harm, disability, or death, and that the provider and associated IPA have advised me of these risks.

I refuse the recommended treatment or procedure
I refuse admission or continued hospitalization
I refuse recommended medications or therapies
I intend to leave the facility against medical advice

The provider has explained reasonable alternatives to the recommended care, including transfer to another facility, outpatient follow-up, and the risks of no treatment. The patient acknowledges understanding of those alternatives.

Confirmations: I understand the risks Alternatives discussed Possible complications explained Follow-up recommended

Attempts to Inform and Witnessed Counseling

Attempts to inform family, legal representative, or primary care provider before patient left:

IPA Notification and Care Coordination

Notification to IPA / primary care physician regarding AMA event:

HIPAA Acknowledgement and Release of Information

I acknowledge that I have been given the facility's privacy practices and have been informed of how my health information will be used for treatment, payment, and healthcare operations. I authorize the release of medical information related to this visit to the IPA, my primary care provider, and other providers involved in my care for continuity purposes as described below.

Authorization expiration date:    I acknowledge receipt of the privacy notice

Provider Attestation

The undersigned provider attests that counseling regarding the recommended treatment, risks, benefits, and alternatives was provided, and that reasonable attempts were made to inform the patient and any available representatives before the patient declined care or left against medical advice.

The provider's signature and formal witnessing are recorded in the facility chart; completion of this form documents the patient's informed refusal and the facility's efforts to counsel and coordinate care through the IPA.

Patient Declaration

I acknowledge that I have read (or had read to me) the information contained in this form, that my questions have been answered to my satisfaction, and that I understand the risks and possible consequences of refusing the recommended care. I accept responsibility for the decision to refuse or discontinue care and release the treating provider and the IPA from liability arising solely from my refusal, except where prohibited by law.

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