The undersigned licensed medical provider, hereby affirms:
1. The below injured patient, has in the opinion of this medical provider, suffered an
Emergency Medical Condition, as a result of the patient’s injuries sustained in an
automobile accident that occurred on _______________________ (fill in date of accident).
The basis for the finding of an Emergency Medical Condition is that the patient has
sustained acute symptoms of sufficient severity, which may include severe pain, such that the
absence of immediate medical attention could reasonably be expected to result in any of the
following: a) serious jeopardy to patient health; b) serious impairment to bodily functions; or
c) serious dysfunction of a bodily organ or part.
I hereby attest that I am a physician licensed under chapter 458 or chapter 459, a dentist licensed
under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced
registered nurse practitioner licensed under chapter 464, and that the above facts are true and
_________________________ ___________________________ ____________
Name (PRINT or TYPE) Signature of medical provider Date
The undersigned injured person or legal guardian of such person affirms:
1. The symptoms I reported to the medical provider are true and accurate
2. I understand the medical provider has determined I sustained an Emergency Medical
Condition as a result of the injuries I suffered in the care accident.
3. The medical provider has explained to my satisfaction the need for future medical attention
and the harmful consequences to my health which may occur if I do not receive future
Injured patient receiving this diagnosis or legal guardian of said injured patient:
______________________ ___________________________________ ____________
Name (PRINT or TYPE) Signature of injured patient/guardian Date
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