Policy Manual sample

MDT Home Health Care Agency, Inc. 197 DISCONTINUANCE OF SERVICE AGAINST MEDICAL ADVICE This is to certify that at my own insistence, and against the advice of the MDT Home Health Care Agency, Inc. and my attending physician, I have been informed by them of the possible adverse consequences of discontinuing the home health services at this time. I release __________________, its employees and officers and my attending physician from all liability for any adverse results caused by my discontinuing the service prematurely. Patient/Legal Representative Signature Date Witness Signature Date MDT Home Health Care Agency, Inc. Representative Signature Date Patient Name: Patient Address: Patient Phone Number: