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  • AMA Form (VMC)

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    James Alan Bush
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    A form I was forced to sign while police officers waited outside my hospital room, which self-releases me from VMC hospital, and which, by inference and implication, I would be arrested for not signing. This is after four days of their refusal to transfer me to another hospital, and after four days of lying about their progress in doing so (it took me 15 minutes on the phone to get my insurance switched to "straight" Medi-Cal, which covers costs at any hospital; VMC insisted that this was not a possibility, and went about looking for options to make me pay for services—even when they could have made an emergency referral, which would have covered costs no matter what insurance plan).

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    A form I was forced to sign while police officers waited outside my hospital room, which self-releases me from VMC hospital, and which, by inference and implication, I would be arrested for not signing. This is after four days of their refusal to transfer me to another hospital, and after four days of lying about their progress in doing so (it took me 15 minutes on the phone to get my insurance switched to "straight" Medi-Cal, which covers costs at any hospital; VMC insisted that this was not a possibility, and went about looking for options to make me pay for services—even when they could have made an emergency referral, which would have covered costs no matter what insurance plan).

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    519 views1 page

    AMA Form (VMC)

    Uploaded by

    James Alan Bush
    A form I was forced to sign while police officers waited outside my hospital room, which self-releases me from VMC hospital, and which, by inference and implication, I would be arrested for not signing. This is after four days of their refusal to transfer me to another hospital, and after four days of lying about their progress in doing so (it took me 15 minutes on the phone to get my insurance switched to "straight" Medi-Cal, which covers costs at any hospital; VMC insisted that this was not a possibility, and went about looking for options to make me pay for services—even when they could have made an emergency referral, which would have covered costs no matter what insurance plan).

    Copyright:

    © All Rights Reserved
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    Santa Clara Valley Medical Center suo 751 South Bascom Avenue VALLEY San Jose, California 95128 LEAVING HOSPITAL AGAINST ADVICE ABANDONO DEL HOSPITAL CONTRA EL CONSEJO MEDICO ROT BENH VIEN NGUO'C VOT LO'I KHUYEN CAO Date/ Fecha/ Ngay _/ Time/ Hora/ Gity This is to certify that . 1 patient in the above named hospital, is leaving the bdepital against is ‘advice of the attending physician. I acknowledge that I have been informed of the risks involved and hereby release the attending physician, and the County of Santa Clara, owner and operator of the hospital, from any liability for any ill effects or injury which may result from leaving the hospital. Esto es para certificar que, , paciente en el hospital nombrado arriba, ests abandonando el hospital contra Tas recomendaciones y el consejo del doctor encargado. Confieso que he sido informado de los riesgos implicados y por este medio libero al doctor encargado y al Condado de Santa Clara, duefio y operador del hospital, de cualquier responsabilidad por efectos de enfermedad o lesién que pudieran resultar por abandonar el hospital Gidy nay dé xe nhan ring __ , 1a bénh nhan cia bénh vién c6 tén ghi trén, ri bénh vién khéng tuan theo Idi khuyén cua y-si diéu t Téi céng nhan rang t6i da duoc gidi thich ré nhitng nguy hiém va t0i dong ¥ gi: t6a moi tréch nhiém cia y si diéu tri, Quin Santa Clara, Chi nhén va ngwoi diéu hanh bénh vign déi voi nhtng hau qué xau ho%c tén throng c6 thé ‘kay ra do su revi bénh vign cia t6i J Patleni/ Paciente/ BeAiahan Other Person Responsible/ Otra persona responsable/ Nguoi c6 tréch nhiém Relationship/ Parenteseo/ Lién Hé Witness/ Testigo/ Nhin Ching Witness/ Testigo/ Nhin Chirng Disposition: White- Medical Chart Pink- To Patient SCVMC 6903-21 SVE987 Lag apt Apis Ae eumel Imi) VNC: agp Serine 102892 Br00

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