S-SV EMS REFUSAL OF CARE FORM (850-A) - S-SV EMS Agency 2025

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The document is a refusal of care form used by Emergency Medical Services (EMS) to document a patient's decision to decline medical assessment, treatment, or transportation. It outlines the patient's rights and responsibilities, the risks associated with refusing care, and the conditions under which a patient can be released at the scene or refuse service against medical advice (AMA). The form requires signatures from the patient or their legal guardian and includes a checklist for EMS personnel to ensure all necessary evaluations and communications have been completed before terminating the patient-EMS relationship.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (115 Votes)
2014	4 Satisfied (20 Votes)
2010	4.3 Satisfied (52 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is patient refusal?

Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.

What is a patient refusal of EMS treatment and or transport?

If a patient refuses treatment or transportation the EMT must 1st involve medical control and note the patients decision and why on your report. The patient will need to sign a refusal form and have a witness signature, if and only if no witnesses are available your partner may sign the form.

What is EMS patient refusal?

Refusal of Medical Assistance (RMA) is a term used in emergency medical services (EMS) to describe situations where a patient declines some or all medical treatment in the pre-hospital setting, such as during an ambulance response.

What is an example of a refusal narrative for EMS?

The refusal of EMS treatment by a patient must be classified as an informed refusal, where the patient understands their condition and the consequences of their decision. This respects their autonomy and does not require court or police involvement.

Can a person refuse care during an emergency?

HIPAA for EMS, or HIPAA for Emergency Medical Services, applies in the same ways in which HIPAA applies to covered entities. This is because EMS providers are involved in the treatment of patients, making EMS a covered entity. More details regarding HIPAA for EMS is discussed below.