(a) Medical screening requirement In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital ’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists. (b) Necessary stabilizing treatment for emergency medical conditions and labor (1) In general If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition , the hospital must provide either— (A) within the staff and facilities available at the hospital , for such further medical examination and such treatment as may be required to stabilize the medical condition, or (B) for transfer of the individual to another medical facility in accordance with subsection (c). (2) Refusal to consent to treatment A hospital is deemed to meet the requirement of paragraph (1)(A) with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of such examination and treatment, but the individual (or a person acting on the individual’s behalf) refuses to consent to the examination and treatment. The hospital shall take all reasonable steps to secure the individual’s (or person’ s) written informed consent to refuse such examination and treatment. (3) Refusal to consent to transfer A hospital is deemed to meet the requirement of paragraph (1) with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with subsection (c) and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of such transfer , but the individual (or a person acting on the individual’s behalf) refuses to consent to the transfer . The hospital shall take all reasonable steps to secure the individual’s (or person’ s) written informed consent to refuse such transfer . (c) Restricting transfers until individual stabilized (1) Rule If an individual at a hospital has an emergency medical condition which has not been stabilized (within the meaning of subsection (e)(3)(B)), the hospital may not transfer the individual unless— (A) (i) the individual (or a legally responsible person acting on the individual’s behalf) after being informed of the hospital ’s obligations under this section and of the risk of transfer , in writing requests transfer to another medical facility, (ii) a physician (within the meaning of section 1395x(r)(1) of this title ) has signed a certification that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting the transfer, or (iii) if a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as defined by the Secretary in regulations ) has signed a certification described in clause (ii) after a physician (as defined in section 1395x(r)(1) of this title ), in consultation with the person, has made the determination described in such clause, and subsequently countersigns the certification; and (B) the transfer is an appropriate transfer (within the meaning of paragraph (2)) to that facility. A certification described in clause (ii) or (iii) of subparagraph (A) shall include a summary of the risks and benefits upon which the certification is based. (2) Appropriate transfer An appropriate transfer to a medical facility is a transfer — (A) in which the transferring hospital provides the medical treatment within its capacity which minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (B) in which the receiving facility— (i) has available space and qualified personnel for the treatment of the individual, and (ii) has agreed to accept transfer of the individual and to provide appropriate medical treatment; (C) in which the transferring hospital sends to the receiving facility all medical records (or copies thereof), related to the emergency condition for which the individual has presented, available at the time of the transfer , including records related to the individual’s emergency medical condition , observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) provided under paragraph (1)(A), and the name and address of any on-call physician (described in subsection (d)(1)(C)) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; (D) in which the transfer is effected through qualified personnel and transportation equipment, as required including the use of necessary and medically appropriate life support measures during the transfer ; and (E) which meets such other requirements as the Secretary may find necessary in the interest of the health and safety of individuals transferred. (d) Enforcement (1) Civil money penalties (A) A participating hospital that negligently violates a requirement of this section is subject to a civil money penalty of not more than $50,000 (or not more than $25,000 in the case of a hospital with less than 100 beds) for each such violation. The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply with respect to a penalty or proceeding under section 1320a–7a(a) of this title . (B) Subject to subparagraph (C), any physician who is responsible for the examination, treatment, or transfer of an individual in a participating hospital , including a physician on-call for the care of such an individual, and who negligently violates a requirement of this section, including a physician who— (i) signs a certification under subsection (c)(1)(A) that the medical benefits reasonably to be expected from a transfer to another facility outweigh the risks associated with the transfer , if the physician knew or should have known that the benefits did not outweigh the risks, or (ii) misrepresents an individual’s condition or other information, including a hospital ’s obligations under this section, is subject to a civil money penalty of not more than $50,000 for each such violation and, if the violation is gross and flagrant or is repeated, to exclusion from participation in this subchapter and State health care programs. The provisions of section 1320a–7a of this title (other than the first and second sentences of subsection (a) and subsection (b)) shall apply to a civil money penalty and exclusion under this subparagraph in the same manner as such provisions apply with respect to a penalty, exclusion, or proceeding under section 1320a–7a(a) of this title . (C) If, after an initial examination, a physician determines that the individual requires the services of a physician listed by the hospital on its list of on-call physicians (required to be maintained under section 1395cc(a)(1)(I) of this title ) and notifies the on-call physician and the on-call physician fails or refuses to appear within a reasonable period of time, and the physician orders the transfer of the individual because the physician determines that without the services of the on-call physician the benefits of transfer outweigh the risks of transfer, the physician authorizing the transfer shall not be subject to a penalty under subparagraph (B). However, the previous sentence shall not apply to the hospital or to the on-call physician who failed or refused to appear. (2) Civil enforcement (A) Personal harm Any individual who suffers personal harm as a direct result of a participating hospital ’s violation of a requirement of this section may, in a civil action against the participating hospital , obtain those damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate. (B) Financial loss to other medical facility Any medical facility that suffers a financial loss as a direct result of a participating hospital ’s violation of a requirement of this section may, in a civil action against the participating hospital , obtain those damages available for financial loss, under the law of the State in which the hospital is located, and such equitable relief as is appropriate. (C) Limitations on actions No action may be brought under this paragraph more than two years after the date of the violation with respect to which the action is brought. (3) Consultation with quality improvement organizations In considering allegations of violations of the requirements of this section in imposing sanctions under paragraph (1) or in terminating a hospital ’s participation under this subchapter, the Secretary shall request the appropriate quality improvement organization (with a contract under part B of subchapter XI) to assess whether the individual involved had an emergency medical condition which had not been stabilized, and provide a report on its findings. Except in the case in which a delay would jeopardize the health or safety of individuals, the Secretary shall request such a review before effecting a sanction under paragraph (1) and shall provide a period of at least 60 days for such review. Except in the case in which a delay would jeopardize the health or safety of individuals, the Secretary shall also request such a review before making a compliance determination as part of the process of terminating a hospital’ s participation under this subchapter for violations related to the appropriateness of a medical screening examination, stabilizing treatment, or an appropriate transfer as required by this section, and shall provide a period of 5 days for such review. The Secretary shall provide a copy of the organization’s report to the hospital or physician consistent with confidentiality requirements imposed on the organization under such part B. (4) Notice upon closing an investigation The Secretary shall establish a procedure to notify hospitals and physicians when an investigation under this section is closed. (e) Definitions In this section: (1) The term “ emergency medical condition ” means— (A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in— (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part; or (B) with respect to a pregnant woman who is having contractions— (i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child. (2) The term “ participating hospital ” means a hospital that has entered into a provider agreement under section 1395cc of this title . (3) (A) The term “ to stabilize ” means, with respect to an emergency medical condition described in paragraph (1)(A), to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition described in paragraph (1)(B), to deliver (including the placenta). (B) The term “ stabilized ” means, with respect to an emergency medical condition described in paragraph (1)(A), that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition described in paragraph (1)(B), that the woman has delivered (including the placenta). (4) The term “ transfer ” means the movement (including the discharge) of an individual outside a hospital’ s facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (A) has been declared dead, or (B) leaves the facility without the permission of any such person. (5) The term “ hospital ” includes a critical access hospital (as defined in section 1395x(mm)(1) of this title ). (f) Preemption The provisions of this section do not preempt any State or local law requirement, except to the extent that the requirement directly conflicts with a requirement of this section. (g) Nondiscrimination A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the Secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual. (h) No delay in examination or treatment A participating hospital may not delay provision of an appropriate medical screening examination required under subsection (a) or further medical examination and treatment required under subsection (b) in order to inquire about the individual’s method of payment or insurance status. (i) Whistleblower protections A participating hospital may not penalize or take adverse action against a qualified medical person described in subsection (c)(1)(A)(iii) or a physician because the person or physician refuses to authorize the transfer of an individual with an emergency medical condition that has not been stabilized or against any hospital employee because the employee reports a violation of a requirement of this section. (Aug. 14, 1935, ch. 531, title XVIII, § 1867, as added Pub. L. 99–272, title IX, § 9121(b) , , 100 Stat. 164 ; amended Pub. L. 99–509, title IX, § 9307(c)(4) , , 100 Stat. 1996 ; Pub. L. 99–514, title XVIII, § 1895(b)(4) , , 100 Stat. 2933 ; Pub. L. 100–203, title IV, § 4009(a)(1) , formerly § 4009(a)(1), (2), , 101 Stat. 1330–56 , 1330–57; Pub. L. 100–360, title IV, § 411(b)(8)(A)(i) , , 102 Stat. 772 ; Pub. L. 100–485, title VI, § 608(d)(18)(E) , , 102 Stat. 2419 ; Pub. L. 101–239, title VI , §§ 6003(g)(3)(D)(xiv), 6211(a)–(h), , 103 Stat. 2154 , 2245–2248; Pub. L. 101–508, title IV , §§ 4008(b)(1)–(3)(A), 4207(a)(1)(A), (2), (3), (k)(3), formerly 4027(a)(1)(A), (2), (3), (k)(3), , 104 Stat. 1388–44 , 1388–117, 1388–124, renumbered and amended Pub. L. 103–432, title I, § 160(d)(4) , (5)(A), , 108 Stat. 4444 ; Pub. L. 105–33, title IV, § 4201(c)(1) , , 111 Stat. 373 ; Pub. L. 108–173, title VII, § 736(a)(14) , title IX, § 944(b), (c)(1), , 117 Stat. 2355 , 2423; Pub. L. 112–40, title II, § 261(a)(3)(A) , (E), , 125 Stat. 423 .)