BiliMed AMA Return Acknowledgment

BiliMed AMA Return Acknowledgment

Please fill this out when you are returning equipment without a Physician's Stop Order
BiliMed, L.L.C. — Against Medical Advice (AMA) Return Acknowledgment

I am requesting to discontinue my BiliMed home phototherapy rental and return the equipment without a physician stop order currently on file.

I understand and acknowledge that:

• This decision is being made against medical advice, without confirmation from my treating physician that phototherapy is no longer needed

• BiliMed has not evaluated my baby’s medical condition and is not providing medical advice by accepting this return

• I am solely responsible for following up with my treating physician regarding my baby’s continued care

• Daily rental charges continue to accrue under my Rental Agreement until the equipment is physically returned to BiliMed — this acknowledgment does not stop billing on its own; it authorizes BiliMed to accept an early, physician-unconfirmed return once scheduled

• I should call or text (337) 509-1818 to schedule my return appointment after submitting this form

BiliMed, L.L.C. | 345 Doucet Road, Suite 200E, Lafayette, LA 70503

(337) 509-1818 | info@bilimed.com
Parent/Guardian Name
Baby's Name (Patient)
Reference ID (if you have one)
Reason for early return (optional)
I acknowledge I have read and understand this Against Medical Advice Statement
Electronic Signature
Typed Full Legal Name
Should be Empty: