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Sample forms:
The following forms samples are provided for informational and educational purposes only. Be certain to consult your hospital counsel for legal advice regarding policies, procedures, and legal obligations under this and other laws. Do not implement forms without appropriate policies and procedures to support their use and to assure compliance with EMTALA provisions. CMS does not require a specific FORM for compliance, but it is highly unlikely that a compliant transfer can be accomplished without reliance upon standardized forms.
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- Transfer form -- single page form including consent and physician certification.
- Patient-initiated transfer form -- to be used in conjuction with a standard transfer form when the patient has requested transfer without any suggestion or pressure by the hospital or physician, and where the hospital would have been able to provide care.
- Mental health assessment form -- to be completed by the examining physician on all patients presenting with mental health primary complaints or secondary observations. This form is in addition to an appropriate medical screening exam to first rule out medical, toxic, or traumatic conditions causing the behavior or masked by the behavior. A supporting narrative is indicated to support observations and conclusions.
- Blood alcohol testing intake form -- for police blood alcohol requests. While these are technically viewed as not requiring an MSE, like all other out-patients presenting to the Emergency Department, the patient must be logged and if the patient requests an assessment or the ED staff notices or is told of circumstances suggesting an exam is necesary, CMS will expect the MSE exam to be performed. This form helps document the information available at the time of presentation and helps guide the nurse in whether the patient will require further triage and MSE.
- Refusal of services form. -- Every time a patient decides to leave, or to refuse services such as an MSE, refuses transfer, refuses a test, or other element of EMTALA compliance, EMTALA requires completion of a refusal form. Many folks confuse this with an AMA -- Against Medical Advice -- but it is not the same as an AMA form because of what is required in it.. The CMS name for this form is "Informed Consent To Refuse which is awkward, but it emphasizes the informed consent aspects of refusing care. A patient may refuse care, and it is not necessarily against medical advice. The important part of this form is that it must tell the patient the RISKS of refusing care or refusing transfer or refusing an ambulance. Rather than having a number of different forms, I have combined these aspects into a single form.
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