Login Hospital's Form Broker's Form VITAS Form Release of Liability Form Account

REGISTER NEW ACCOUNT

Release of Liabaility and Assumption of Risk Agreement

CMT Ambulance Services / Care Medical Transportation

Patient Information

Patient Name:

Date of Birth:

Date of Service:

Pickup Location:

Destination:

I, the undersigned patient, legal guardian, or authorized representative, voluntarily request transportation services from CMT Ambulance Services / Care Medical Transportation ("Company").

By signing this Release of Liability and Assumption of Risk Agreement, I acknowledge and agree to the following:

1. VOLUNTARY PARTICIPATION

I understand that I am voluntarily accepting transportation services provided by the Company. I acknowledge that transportation may involve certain inherent risks, including but not limited to traffic accidents, delays, sudden medical complications, road conditions, weather-related events, and other circumstances beyond the Company's reasonable control.

I acknowledge and agree.

2. MEDICAL CONDITION DISCLOSURE

I certify that I have disclosed all known medical conditions, mobility limitations, special transportation requirements, medications, and any other information necessary to ensure safe transportation. I understand that failure to provide complete and accurate information may increase the risks associated with transportation.

I certify this information is accurate.

3. NON-GUARANTEE OF MEDICAL OUTCOMES

I understand that the Company and its employees, agents, contractors, and representatives do not guarantee any specific medical outcome, recovery, improvement, or result from the transportation services provided.

I understand and agree.

4. RELEASE OF LIABILITY

To the fullest extent permitted by law, I hereby release, waive, discharge, and hold harmless CMT Ambulance Services / Care Medical Transportation, its owners, officers, directors, employees, agents, contractors, successors, and assigns from any and all claims, demands, causes of action, damages, losses, liabilities, costs, or expenses arising out of or related to the transportation services provided, except in cases of gross negligence, willful misconduct, or violations of applicable law.

I have read and agree to the Release of Liability.

5. EMERGENCY MEDICAL CARE

In the event of a medical emergency during transport, I authorize Company personnel to contact emergency medical services, notify appropriate healthcare providers, and take reasonable actions necessary to protect the health and safety of the patient.

I authorize emergency medical actions as described above.

6. INSURANCE AND BILLING

I understand that I remain financially responsible for any transportation charges not covered by Medicare, Medicaid, private insurance, managed care organizations, or any other third-party payer. I agree to provide all necessary insurance and billing information required for processing claims.

I understand and agree.

7. ACKNOWLEDGMENT OF RISKS AND RIGHTS

I have carefully read this document and fully understand its contents. I acknowledge that I have had the opportunity to ask questions regarding this agreement and understand that by signing it, I may be waiving certain legal rights. I voluntarily agree to its terms and conditions.

I acknowledge that I have read and understand this agreement.

8. SAFE TRANSPORT AND ACCEPTANCE OF CARE

I acknowledge and confirm that the patient identified in this agreement was transported by CMT Ambulance Services / Care Medical Transportation to the requested destination and was delivered safely.

I further acknowledge that the patient was released into the care, custody, and supervision of the undersigned patient, legal guardian, authorized representative, family member, caregiver, facility representative, or other authorized receiving party.

By signing below, I certify that:

The patient arrived at the destination in satisfactory condition as observed at the time of transfer.

I have accepted responsibility for the patient's care and supervision upon completion of transport.

I have been given the opportunity to inspect the patient and report any concerns at the time of transfer.

I understand that CMT Ambulance Services / Care Medical Transportation's responsibility for the patient ends upon the patient's safe transfer and acceptance by the receiving individual or facility, except as otherwise required by applicable law.

RECEIVING PARTY ACKNOWLEDGMENT

Receiving Party Name:

Relationship to Patient:

Destination / Facility:

Date:

Time:

Signature of Receiving Party:

By typing my full legal name below, I acknowledge that this electronic signature is legally binding and has the same force and effect as a handwritten signature.

PATIENT / LEGAL GUARDIAN AUTHORIZATION

I certify that I am the patient or the patient's authorized legal representative and that I have read, understood, and voluntarily agree to the terms of this Release of Liability and Assumption of Risk Agreement.

Patient / Legal Guardian Name:

Relationship to Patient (if applicable):

Date:

Signature:

By typing my full legal name below, I acknowledge that this electronic signature is legally binding and has the same force and effect as a handwritten signature.

CMT AMBULANCE SERVICES REPRESENTATIVE

Employee Name:

Date:

Time:

Signature:

By typing my full legal name below, I acknowledge that this electronic signature is legally binding and has the same force and effect as a handwritten signature.

I certify that the information provided is true and accurate and that all required signatures have been obtained.

Release of Liability Agreement submitted successfully. A confirmation email has been sent.

Error submitting form. Please check your information and try again.

Quick links Support Resources Contact Help

© 2024 Care Med Trans. All rights reserved.

Privacy policy Terms of service Cookie settings