Alabama Patient Consent to Diagnosis, Treatment, and Related Procedures
(Comprehensive Legal Template – Court-Ready Format)
[// GUIDANCE: This form is drafted to comply with Alabama informed-consent doctrine, Ala. Code §§ 22-8-4 et seq. (capacity of minors); the Alabama Medical Liability Act; HIPAA (45 C.F.R. pt 164); and general principles of medical-malpractice law. Customize all bracketed items before use.]
I. DOCUMENT HEADER
1. Parties
This Patient Consent Form (the “Agreement”) is made and entered into effective as of [EFFECTIVE DATE] (the “Effective Date”) by and between:
(a) [LEGAL NAME OF HEALTH-CARE PROVIDER], an Alabama licensed [Hospital / Clinic / Physician Practice] (“Provider”); and
(b) [FULL LEGAL NAME OF PATIENT], date of birth [DOB], or the undersigned legally-authorized representative of Patient under Ala. Code § 22-8-4 (the “Patient”).
2. Recitals
A. Provider has advised Patient of the need for and nature of the proposed examination, treatment, or procedure described herein (the “Treatment Plan”).
B. Patient desires to receive the Treatment Plan and is willing to grant informed consent under the terms set forth below.
C. In consideration of the mutual covenants herein, and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows.
II. DEFINITIONS
For purposes of this Agreement, the following terms have the meanings set forth below. Defined terms appear in bold-italics throughout.
- “Capacity” means the ability to understand the nature and consequences of the Treatment Plan and to make an informed, voluntary decision regarding such Treatment Plan.
- “Covered Entities” means Provider and any affiliate, employee, contractor, or agent participating in the Treatment Plan.
- “HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and implementing regulations at 45 C.F.R. pt 164.
- “Informed Consent Standards” means the duty under Alabama law to disclose those material risks, benefits, and alternatives that a reasonable person in the Patient’s position would deem significant in making a decision regarding treatment.
- “Malpractice Limits” means any statutory or common-law cap or limitation on damages recoverable against health-care providers under the Alabama Medical Liability Act, as amended.
- “Representative” means an individual authorized under applicable law to act on Patient’s behalf, including but not limited to a parent, guardian, healthcare proxy, or attorney-in-fact.
- “Treatment Plan” means the medical or surgical procedure(s), course of treatment, or diagnostic evaluation specifically described in Section 3.1.
III. OPERATIVE PROVISIONS
3.1 Consent to Treatment Plan
Patient hereby authorizes Provider to perform [DETAILED DESCRIPTION OF PROCEDURE / COURSE OF TREATMENT], together with any ancillary services or procedures reasonably related thereto, including administration of medications, anesthesia, radiographic or laboratory studies, and the use of telehealth modalities where clinically appropriate.
3.2 Scope of Authorization
a. Substituted Procedures. If, during the course of the Treatment Plan, Provider determines that unforeseen conditions necessitate additional or different procedures, Patient authorizes Provider to perform such procedures as are, in Provider’s professional judgment, immediately necessary to preserve life or prevent material impairment of health.
b. Refusal / Withdrawal. Patient retains the right to refuse or withdraw consent at any time prior to commencement or completion of the Treatment Plan, subject to Section 6 (Default & Remedies).
3.3 Disclosure Requirements Fulfilled
Provider represents that, prior to execution of this Agreement, Provider has disclosed and explained to Patient, in a manner consistent with the Informed Consent Standards:
1. The diagnosis and proposed Treatment Plan;
2. The material risks and frequent or significant complications;
3. Reasonable alternatives, including the option of no treatment;
4. The likely benefits, prognosis, and expected outcome;
5. The names and professional designations of principal practitioners; and
6. Expected recovery time and post-treatment obligations.
3.4 Capacity Verification
Provider has reasonably confirmed, and Patient hereby represents, that Patient possesses Capacity. If Patient lacks Capacity, the Representative executing this Agreement on Patient’s behalf affirms his/her authority under Ala. Code § 22-8-4 or other applicable law.
3.5 Consideration
Provider’s agreement to render the Treatment Plan constitutes sufficient consideration for Patient’s promises, representations, and risk allocations herein. Any financial obligations of Patient are governed by Section 3.6.
3.6 Payment Terms
a. Patient shall remain responsible for all charges not paid by insurance or other third-party payors, in accordance with Provider’s standard billing policies.
b. Amounts past due more than [##] days shall accrue interest at the lesser of [## %] per annum or the maximum rate permitted by Alabama law.
c. Provider may employ customary collection remedies subject to Section 6.2 (Notice & Cure).
IV. REPRESENTATIONS & WARRANTIES
4.1 Patient Representations
Patient (or Representative) represents and warrants that:
a. All medical history and information provided is complete and accurate;
b. Patient has had ample opportunity to ask questions and obtain satisfactory explanations;
c. Execution of this Agreement is voluntary and free from duress; and
d. Patient is not relying on any oral statements inconsistent with this Agreement.
4.2 Provider Representations
Provider represents and warrants that it:
a. Holds all licenses, permits, and accreditations required under Alabama and federal law;
b. Will exercise that degree of care, skill, and diligence reasonably expected of similarly situated Alabama health-care providers; and
c. Maintains professional liability insurance in at least the minimum amounts mandated by Alabama law.
4.3 Survival
All representations and warranties shall survive completion of the Treatment Plan for the longest period permitted by applicable statute of limitations.
V. COVENANTS & RESTRICTIONS
5.1 Compliance Covenant
Each party agrees to comply in all material respects with all applicable federal and Alabama statutes, regulations, and professional standards, including without limitation HIPAA, the Alabama Medical Liability Act, and the Alabama Board of Medical Examiners rules.
5.2 Patient Cooperation
Patient shall follow Provider’s pre-operative and post-operative instructions, attend follow-up appointments, and promptly report any unexpected or adverse symptoms.
5.3 No Assignment
Neither party may assign or delegate its rights or duties under this Agreement without the prior written consent of the other, except that Provider may assign for billing or collection purposes.
VI. DEFAULT & REMEDIES
6.1 Events of Default
a. Patient’s material breach of Section 5.2 (Patient Cooperation) or failure to satisfy financial obligations under Section 3.6.
b. Provider’s material breach of Section 4.2 (Provider Representations).
6.2 Notice & Cure
The non-breaching party shall deliver written notice specifying the default. The breaching party shall have [15] days (or 24 hours for urgent clinical matters) to cure before further remedies accrue.
6.3 Graduated Remedies
a. Provider Remedies (Patient Default). Suspension of non-emergency treatment; referral to alternate providers; and collection of amounts due, including reasonable attorney fees.
b. Patient Remedies (Provider Default). Termination of this Agreement; seeking alternative medical care; and pursuit of any legal remedies available under Alabama law.
VII. RISK ALLOCATION
7.1 Indemnification by Patient
To the fullest extent permitted by Alabama law, Patient shall indemnify and hold harmless Provider from any loss, claim, or expense arising out of (i) Patient’s breach of this Agreement, or (ii) inaccurate or incomplete medical information supplied by Patient, except to the extent caused by Provider’s negligence or willful misconduct.
7.2 Limitation of Liability
Provider’s aggregate liability to Patient for monetary damages shall not exceed the Malpractice Limits. Nothing herein shall be construed to reduce or expand any statutory limitation or to waive sovereign or charitable immunities, if applicable.
7.3 No Waiver of Non-Economic Damages
Nothing in this Agreement shall be interpreted to waive Patient’s right to pursue non-economic damages where such waiver is prohibited by Alabama law.
7.4 Force Majeure
Neither party shall be liable for failure or delay in performance caused by events beyond its reasonable control, including acts of God, governmental actions, or public health emergencies, provided that the affected party gives prompt notice and resumes performance as soon as practicable.
VIII. DISPUTE RESOLUTION
8.1 Governing Law
This Agreement and any dispute arising hereunder shall be governed by the internal laws of the State of Alabama without regard to its conflict-of-laws rules.
8.2 Forum Selection
Subject to Section 8.3, the parties submit to the exclusive jurisdiction of the state courts of competent jurisdiction sitting in [COUNTY], Alabama.
8.3 Optional Arbitration
[ ] Elect Arbitration – If this box is checked and initialed by both parties, any dispute shall be resolved by binding arbitration administered by [AAA / JAMS] in accordance with its healthcare rules then in effect. The arbitration shall take place in Alabama, and judgment on the award may be entered in any court of competent jurisdiction.
[// GUIDANCE: Alabama enforces voluntary, written arbitration agreements in healthcare, provided statutory notice of patient rights is given. Tailor this clause to Provider policy.]
8.4 Preservation of Jury Trial
If Section 8.3 is not elected, the parties acknowledge Patient’s inviolate constitutional right to trial by jury under Ala. Const. art. I, § 11, and no contractual jury waiver is imposed.
8.5 Injunctive Relief
Either party may seek equitable relief only to the limited extent necessary to (i) protect HIPAA-protected information, or (ii) prevent irreparable clinical harm, provided that any such relief shall not exceed what is reasonably necessary under the circumstances.
IX. GENERAL PROVISIONS
9.1 Amendment; Waiver
No amendment or waiver of any provision of this Agreement shall be effective unless in writing and signed by both parties. A waiver of any breach shall not operate as a waiver of any subsequent breach.
9.2 Severability
If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be deemed modified to the minimum extent necessary to render it valid and enforceable.
9.3 Integration
This Agreement constitutes the entire agreement between the parties concerning the subject matter and supersedes all prior oral or written communications.
9.4 Counterparts; Electronic Signatures
This Agreement may be executed in multiple counterparts, each of which shall be deemed an original, and all of which together constitute one instrument. Signatures delivered electronically (including via DocuSign® or similar platform) shall be deemed original.
9.5 Successors & Assigns
Subject to Section 5.3, this Agreement shall bind and inure to the benefit of the parties and their respective heirs, legal representatives, successors, and permitted assigns.
X. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Agreement as of the Effective Date.
10.1 Patient / Representative
Signature
Name: ____
Capacity: ☐ Patient ☐ Parent ☐ Guardian ☐ Other: _
Date: _______
10.2 Provider
Authorized Signature
Name: ____
Title: ____
Date: _______
10.3 Witness (Recommended)
Signature of Witness
Name: ____
Date: ____
10.4 Notary Acknowledgment (If Required)
State of Alabama )
County of ____ )
On this ___ day of _, 20_, before me, ____, a Notary Public in and for said state, personally appeared ________, known to me (or proved to me) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he/she executed the same for the purposes therein contained.
Witness my hand and official seal.
Notary Public
My Commission Expires: ____
[// GUIDANCE:
1. Attach supplementary “Risk-Benefit Disclosure Sheet” and “Financial Responsibility Agreement” if used by Provider.
2. For minors, include additional signature lines and confirm compliance with Ala. Code §§ 22-8-1 to -4.
3. Verify that the arbitration election language complies with Ala. Code § 6-5-485 et seq. (if applicable).
4. Store executed originals in Patient’s medical record in accordance with HIPAA retention requirements (six years minimum).]