Refusal of Care Against Medical Advice
Criteria for refusing care
The patient meets all of the following:
1. Is a patient over the age of 18 yrs.
2. Exhibits no evidence of:
Altered level of consciousness
Alcohol or drug ingestion that would impair judgment
3. Understands the nature of the medical condition, as well as the risks and consequences of
1. Acknowledgement of Information (Initial on line)
a. ____I have been advised that medical care on my behalf is necessary, and that
refusal of care and assistance could be hazardous to my health, and under
certain circumstances, including disability or death.
b. ____I acknowledge that I may have a medical problem which may require
additional medical attention, and that NDSP or an ambulance is available to
transport me to the hospital. Instead, I elect to seek alternative medical care
and/or refuse further evaluation, treatment and/or transport.
2. Release of Liability (initial on line)
____ By signing this form, I am releasing University Health Services, Notre Dame,
of any liability or medical claims resulting from my decision to refuse care against
I have read and understand the Acknowledgement of Information and Release of Liability.
If you change your mind, or your condition changes, call 911 in an emergency, go
to Memorial Hospital emergency room on 933N in South Bend or Saint Joseph
Regional Medical Center on Douglas Rd/Holy Cross Drive in Mishawaka, or call
your private doctor, if appropriate.
Signature:___________________________ Name Printed:_____________________________