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EMERGENCY MEDICAL CARE REFUSAL FORM PARTICIPANT COMPLETION (To be completed by participant signing on own behalf) Instructions: Only complete this form if you do not consent to emergency medical care

How to fill out emergency medical care refusal

Who needs emergency medical care refusal?

Emergency medical care refusal forms are typically needed by individuals who do not wish to receive medical treatment in emergency situations. It is important for individuals who are of sound mind and capable of making their own medical decisions to have this form in place in case they ever find themselves in a situation where emergency medical care is being offered but they wish to decline it. This could include individuals who have specific religious or personal beliefs that prevent them from accepting certain medical treatments, as well as those who have made advance healthcare directives outlining their wishes for specific medical interventions.

How to fill out emergency medical care refusal:

1. Familiarize yourself with the form: Start by reviewing the emergency medical care refusal form provided by your healthcare provider or legal authority. This document may also be known as a "do not resuscitate" (DNR) or "do not attempt resuscitation" (DNAR) form. Ensure that you understand the purpose and implications of the form before proceeding.
2. Complete personal information: Begin by providing your personal information on the form. This usually includes your full name, date of birth, address, and contact details. Some forms may also require you to include your healthcare provider's information or the details of your designated healthcare proxy or power of attorney.
3. Specify emergency medical interventions: This section of the form allows you to indicate which emergency medical treatments you do not wish to receive. Common interventions may include cardiopulmonary resuscitation (CPR), intubation, mechanical ventilation, defibrillation, and other life-saving measures. Make sure to go through each option carefully and mark your preferences clearly. If there are any specific treatments or interventions that you would like to discuss with your healthcare provider, jot them down for future reference.
4. Provide witness information: Most emergency medical care refusal forms require the presence of witnesses who can attest to the fact that you are of sound mind and making an informed decision. Find reliable individuals, such as friends, family members, or healthcare professionals, who are willing to serve as witnesses. Fill out their names, addresses, and other requested details as specified on the form.
5. Review and sign the form: Once you have completed all the necessary sections of the form, carefully review your entries to ensure accuracy. If you have any doubts or questions, consult with your healthcare provider or legal advisor. Once you are confident that the information provided is accurate and reflects your wishes, sign and date the form in the designated areas.
6. Distribute copies: It is essential to distribute copies of the completed emergency medical care refusal form to relevant parties. This may include your healthcare provider, designated healthcare proxy, family members, and any other individuals involved in your care. Keep the original form in a safe and easily accessible place, and consider carrying a wallet-sized card or wearing a medical alert bracelet that indicates your refusal of emergency medical care.

Remember that emergency medical care refusal forms are legally binding documents, so it is important to approach the process thoughtfully and seek appropriate guidance when necessary. Regularly review and update the form as needed to ensure that it accurately reflects your current wishes and circumstances.

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What is emergency medical care refusal?

Emergency medical care refusal is when a patient decides to decline or reject medical treatment or care in an emergency situation.

Who is required to file emergency medical care refusal?

The patient or their legal guardian is typically required to file emergency medical care refusal.

How to fill out emergency medical care refusal?

Emergency medical care refusal can be filled out by providing a written statement or completing a specific form provided by the healthcare facility.

What is the purpose of emergency medical care refusal?

The purpose of emergency medical care refusal is to acknowledge the patient's decision to decline medical treatment and ensure that healthcare providers are aware of this decision.

What information must be reported on emergency medical care refusal?

The emergency medical care refusal should include the patient's name, date of birth, reason for refusal, and signature.