S-SV EMS REFUSAL OF CARE FORM (850-A) - S-SV EMS Agency 2026

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The document is a S-SV EMS Refusal of Care Form (850-A) that allows patients to refuse medical assessment, treatment, or transportation by emergency medical services (EMS). It outlines the conditions under which a patient can refuse care, the responsibilities of EMS personnel, and the potential risks associated with such refusals. The form requires signatures from the patient or their legal guardian and includes a checklist for EMS providers to ensure all necessary steps are taken before accepting a refusal.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name and date of birth at the top of the form. This information is crucial for identification.
Fill in the date of the incident, along with the base or modified base hospital details. Ensure accuracy as this affects medical records.
Indicate whether the patient is being released at scene (RAS) or refusing against medical advice (AMA) by checking the appropriate box.
In the section provided, check all applicable reasons for refusal, such as refusing medical assessment or treatment. This helps clarify the patient's decision.
Ensure that both patient and witness signatures are obtained where required. If a guardian is signing, their relationship to the patient must be noted.
Review all entries for completeness and accuracy before finalizing. This ensures that all necessary information is documented correctly.

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