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1. Patient Information: Patient's full legal name, date of birth, medical record number, and contact information
2. Treatment/Procedure Description: Detailed description of the specific medical treatment, procedure, or intervention being refused
3. Risks and Consequences: Comprehensive explanation of potential medical outcomes, complications, and risks associated with refusing treatment
4. Alternative Options: Description of any alternative treatments or procedures available to the patient
5. Acknowledgment Statement: Patient's formal confirmation of understanding the risks and voluntary nature of the refusal
6. Signature Block: Designated areas for patient/legal representative signature, date, and witness signatures
1. Interpreter Declaration: Section for interpreter certification when patient's primary language is not English
2. Religious Objection Statement: Specific section detailing religious grounds for treatment refusal
3. Capacity Assessment Documentation: Section for healthcare provider to document patient's mental capacity to make medical decisions
4. Healthcare Provider Statement: Section for healthcare provider to document attempts to explain risks and alternatives
1. Medical Information Sheet: Detailed medical information about the refused treatment, including statistics and outcomes
2. Alternative Treatment Options: Comprehensive list of alternative treatments or procedures available to the patient
3. State-Specific Requirements: Additional documentation requirements based on specific state laws and regulations
4. Patient Rights Information: Summary of patient rights regarding treatment refusal under applicable laws
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