Healthcare Surrender Form

HEALTHCARE SURRENDER FORM

Patient Name:    Date of Birth:    Medical Record/ID #:

Patient Information

Insurance Information

Medical History (brief)

Description of Care or Treatment Being Surrendered

I hereby voluntarily surrender the right to receive the following healthcare services, treatments, or ongoing care as described below. I understand that surrendering care may result in the provider ceasing treatment, transferring care, or initiating discharge procedures.

Risks, Benefits, and Consequences

The treating clinician has explained the recommended treatment, anticipated benefits, and reasonably foreseeable risks of withholding or discontinuing the recommended care, which may include but are not limited to delay in recovery, worsening of condition, permanent impairment, or death. I acknowledge that I have been informed of reasonable alternatives to the recommended care and the probable risks and benefits of those alternatives.

Acknowledgment, Release and Assumption of Risk

By signing below I acknowledge that I am at least 18 years of age or am the duly authorized legal guardian or personal representative of the patient and have authority to make healthcare decisions. I understand that:

1. I have been informed in plain language of the nature of the recommended care, reasonable alternatives, and the likely consequences of refusing or discontinuing care.
2. I voluntarily choose to surrender the specified care despite the advice of the treating clinician and the risks explained to me.
3. I release and discharge the provider, facility, employees, agents, and affiliated clinicians from liability for any adverse outcomes that result from my decision to surrender the care, except to the extent caused by the provider's gross negligence or willful misconduct.
4. I understand that surrendering care does not limit my right to seek care elsewhere and that the provider may take reasonable steps to arrange alternative care or transfer of records as appropriate.

I confirm that I had the opportunity to ask questions and that all questions were answered to my satisfaction. I understand that I may revoke this surrender in writing at any time prior to discharge or transfer, except where reversal is impracticable or would jeopardize my safety.

  I acknowledge that I understand the information above, that surrender is voluntary, and I accept the risks and consequences described.

HIPAA and Authorization for Release

I understand that surrendering care may involve disclosure or transfer of medical information to other providers or facilities to ensure continuity of care. I acknowledge receipt of the facility's privacy practices and authorize the release of relevant medical records to facilitate transfer or future treatment, subject to applicable law.

  I acknowledge receipt of privacy information and authorize release of records as necessary for continuity of care.

Assignment of Decision-Making (optional)

If you are surrendering the authority to make healthcare decisions to another individual, provide their information below. This assignment is limited to the scope described above and does not substitute for a formal durable power of attorney for healthcare unless otherwise executed in accordance with applicable law.

Additional Statements

I understand that this Healthcare Surrender Form documents a voluntary relinquishment of the specified healthcare services and does not constitute abandonment, provided the facility makes reasonable efforts to arrange for transfer or alternative care as required by applicable regulatory standards.

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