Healthcare Discharge Release

Healthcare Discharge Release

Patient Information

Patient Name:    Date of Birth:

Insurance & Responsible Party

Admission and Discharge Details

Facility Name:

Attending Physician:

Admission Date:    Discharge Date:

Clinical Summary

Medications & Equipment

Disposition and Follow-Up

Disposition (check all that apply):

Home    Rehabilitation    Skilled Nursing    Transfer to another facility    Left Against Medical Advice

Date:    Time:

Medical History (for discharge record)

Acknowledgment, Release, and Consent

I, the undersigned, affirm that I have been informed of my clinical status, the risks associated with discharge, and the recommended aftercare and follow-up. I acknowledge that the facility and its staff have explained the discharge instructions to me in terms I understand, and I have been given an opportunity to ask questions.

By signing below I release, discharge and hold harmless the facility, its officers, employees, contractors and agents from liability for the continuation of care after the time and date of discharge except for acts of gross negligence or willful misconduct. This release includes claims for failure to provide services after discharge where facilities have provided discharge instructions and reasonable transitional arrangements as documented herein.

I understand that I retain the right to seek further medical care and that this Release does not bar appropriate claims arising from negligent or wrongful acts of the facility occurring prior to the effective time of discharge noted above.

Discharge Against Medical Advice (if applicable): If I leave against medical advice, I acknowledge that clinically advised treatment may not be completed and that such departure may increase the risk of adverse outcomes. I accept responsibility for the decision to leave and release the facility for foreseeable consequences resulting from leaving before recommended completion of care.

HIPAA & Release of Information

I acknowledge receipt of the facility's Notice of Privacy Practices describing how my medical information may be used and disclosed. I authorize the facility to release medical information to my primary care provider, my listed emergency contact, and other treating providers as necessary to facilitate continuity of care. This authorization is valid through the date specified below unless revoked in writing.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it.

Patient Rights and Notices

I have been informed of my right to receive a copy of this signed Discharge Release and a copy of my discharge instructions. I understand my rights to request clarification, to request amendments to my medical record where permitted, and to obtain a copy of certain disclosures of my health information.

I certify that the information I have provided on this form is true and accurate to the best of my knowledge.

Sign Now