Documents the patient's informed refusal of a recommended treatment, test, medication, or hospitalization, confirming that risks of refusal were explained and that the patient is making a voluntary, competent decision.
The Refusal of Treatment / Against Medical Advice is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers ama, refusal, informed consent. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Refusal of Treatment / Against Medical Advice **Practice Name:** ___________ **Attending Provider:** ___________ This document records your decision to refuse a specific medical recommendation made by your provider at this practice. Your provider is required to document this refusal to protect both your safety and the integrity of your medical record. Signing this form is entirely voluntary; you will continue to receive care for other needs. --- ## Patient Information **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number (if known):** ___________ **Date of Encounter:** ___________ **Location:** ___________ --- ## Recommended Treatment, Test, or Intervention **Description of Recommended Care** (the specific treatment, test, medication, procedure, admission, or referral being refused): ___________ **Medical Reason for Recommendation** (why the provider recommended this care): ___________ --- ## Risks of Refusal My provider has explained the potential consequences of declining the recommended care. I understand that refusing may result in: