A world responsible, accountable and engaged in best practices.

Dedicated to helping you understand what quality care should look like and striving to make it accessible for everyone.

Download as a Word Document
Download as a PDF  

LIFT ASSIST
NONTREATMENT AND OR NONTRANSPORT
AGREEMENT
RELEASE OF RESPONSIBILITY

This is to certify that I, _________________________ acknowledge I am not injured and that there is no emergent need for treatment and or transport.  I request that staff provide assistance to lift and return me to a place of comfort. As needed, I have made or will make arrangements for alternative means of transportation and will contact the health care provider of my choice (personal physician, urgent care center, emergency department, or other healthcare provider) to address my medical needs. I acknowledge that I have been informed of the following:

  1. The nature and potential of illness or injury
  2. The potential risks of refusing and or delaying treatment and or transportation up to and including death
  3. The availability of ambulance transportation to a hospital for treatment
  4. Staff have evaluated me within their scope of practice and within their standard of care based upon and I understand that this evaluation is not a diagnosis

 

___        Released in care of self
___        Released in care of friend, relative or staff  

Name_________________________ Relationship_________________________

Patient/Resident/Responsible Party Signature______________________________  

Must be signed by the patient or legal guardian/POA      

Recent Donations

May 01 2021
$272.00
Tracey Jaon Moroney
May 10 2021
$200.00
Stephanie Kain Johnson
May 12 2021
$400.00
Ian Wagner
May 12 2021
$1,000.00
James and Lisa  Mullany

RightCare Newsletter