PATIENT CONSENT TO TREATMENT & ACKNOWLEDGMENT OF DISCLOSURES
(Colorado Informed-Consent–Compliant Template)
[// GUIDANCE: This template is drafted to comply with Colorado informed-consent and disclosure standards, Colorado malpractice-damage limitations, and general health-care–provider risk-management best practices. Customize bracketed items, delete inapplicable provisions, and confirm compatibility with Provider-specific policies.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title & Parties
This Patient Consent to Treatment & Acknowledgment of Disclosures (the “Agreement”) is entered into by:
a. Provider: [LEGAL NAME OF HEALTH-CARE PROVIDER], a [State] [entity type] located at [address]; and
b. Patient: [LEGAL NAME OF PATIENT], date of birth [DOB] (or the undersigned Patient Representative as defined below).
1.2 Effective Date
This Agreement is effective as of the date of Patient’s (or Patient Representative’s) signature (“Effective Date”).
1.3 Jurisdiction
The parties acknowledge that this Agreement and all treatment contemplated herein are governed by the laws of the State of Colorado.
1.4 Recitals
WHEREAS, Provider will furnish certain medical, surgical, diagnostic, therapeutic, or related health-care services to Patient (collectively, the “Treatment”); and
WHEREAS, Colorado law requires that patients (or their legal representatives) provide voluntary and informed consent to Treatment after receiving disclosures of material risks, benefits, and alternatives;
NOW, THEREFORE, in consideration of the mutual promises herein, the parties agree as follows.
2. DEFINITIONS
For purposes of this Agreement, capitalized terms have the meanings set forth below. Undefined capitalized terms used elsewhere shall have the contextually appropriate meaning.
“Arbitration Election” – Patient’s written election, if any, to submit Disputes to binding arbitration pursuant to Section 8.3.
“Capacity” – Legal ability under Colorado law to understand relevant information, appreciate the reasonably foreseeable consequences of decisions, and communicate a choice.
“Informed Consent Disclosures” – The disclosures of material information required under Colorado informed-consent standards, including but not limited to: (i) diagnosis, (ii) nature and purpose of proposed Treatment, (iii) material risks and benefits, (iv) reasonable alternatives—including the option of no treatment—and their risks and benefits, and (v) answers to Patient questions.
“Patient Representative” – A parent, legal guardian, agent under valid medical power of attorney, or other person authorized under Colorado law to make health-care decisions for Patient.
“Protected Health Information” or “PHI” – The term as defined in 45 C.F.R. § 160.103.
“Treatment” – All medical, surgical, diagnostic, therapeutic, rehabilitative or ancillary services rendered by Provider to Patient under this Agreement, including telehealth encounters.
3. OPERATIVE PROVISIONS
3.1 Consent to Treatment
(a) Patient hereby voluntarily consents to Provider’s performance of the Treatment described in Provider’s Informed Consent Disclosures, including administration of medications, anesthesia, transfusion of blood products, use of diagnostic devices, and ancillary services reasonably related thereto.
(b) Scope. This consent applies to recurring outpatient visits occurring within [12] months of the Effective Date unless earlier revoked in writing.
3.2 Informed Consent Disclosures
Provider has furnished, and Patient acknowledges receipt of, Informed Consent Disclosures for each significant procedure. Patient has had adequate opportunity to ask questions and obtain satisfactory answers.
3.3 Capacity & Language Assistance
(a) By signing below, the individual giving consent affirms Capacity.
(b) If interpretation or translation assistance is required, Provider shall supply qualified personnel and document the same in Section 10.4.
3.4 Financial Responsibility & Assignment of Benefits
Patient agrees to:
(i) pay all charges not covered by insurance or third-party payors;
(ii) assign insurance benefits directly to Provider; and
(iii) comply with Provider’s financial policies delivered contemporaneously herewith.
3.5 Telehealth Services
Patient consents to receive Treatment via telehealth technologies where clinically appropriate and acknowledges disclosure of telehealth limitations and security risks.
3.6 HIPAA Acknowledgment
Patient acknowledges receipt of Provider’s HIPAA Notice of Privacy Practices and authorizes Provider’s use and disclosure of PHI for Treatment, Payment, and health-care Operations (“TPO”) purposes.
3.7 Conditions Precedent
Provider’s obligation to render Treatment is conditioned upon:
(a) completion of requisite medical history and screening forms;
(b) Patient’s compliance with pre-procedure instructions; and
(c) if applicable, verification of insurance eligibility.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient Reps & Warranties
(a) Information Accuracy. Patient represents that all medical history and insurance information provided is accurate and complete.
(b) No Coercion. Patient affirms decision-making free from coercion, undue influence, or substances impairing judgment.
4.2 Provider Reps & Warranties
(a) Licensure & Qualifications. Provider warrants that individuals delivering Treatment are duly licensed/credentialed under Colorado law.
(b) Standard of Care. Provider will exercise that degree of care, skill, and learning ordinarily possessed and exercised by health-care providers in good standing in similar communities under like circumstances.
4.3 Survival
Representations & Warranties in this Section survive completion of Treatment for the longest duration permitted by applicable limitation periods.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants
(a) Cooperation. Patient shall follow Provider’s instructions, attend follow-up appointments, and promptly report unexpected symptoms.
(b) Payment. Patient shall timely pay all amounts due under Section 3.4.
5.2 Provider Covenants
(a) Records. Provider shall maintain medical records in accordance with Colorado retention requirements.
(b) Compliance. Provider shall comply with all applicable federal and Colorado laws, regulations, and professional guidelines.
6. DEFAULT & REMEDIES
6.1 Events of Default
(a) Patient Default includes: (i) failure to pay when due; (ii) material breach of Section 5.1; or (iii) providing materially false information.
(b) Provider Default includes: (i) material breach of Standard of Care; or (ii) material violation of privacy obligations.
6.2 Notice & Cure
The non-defaulting party must give written notice specifying the default. The defaulting party has [30] calendar days (or shorter period if clinically necessary) to cure, except defaults under Standard of Care require immediate remedial action.
6.3 Remedies
(a) Provider Remedies. Upon Patient Default, Provider may (subject to EMTALA and ethical obligations) suspend non-emergency Treatment, pursue collection, and recover reasonable attorneys’ fees and costs.
(b) Patient Remedies. Upon Provider Default, Patient may pursue Dispute Resolution per Section 8.
7. RISK ALLOCATION
7.1 Indemnification – Informed Consent Protection
Patient (or Patient Representative) shall indemnify and hold harmless Provider from any losses arising from Patient’s breach of Section 4.1 or 5.1, except to the extent caused by Provider’s negligence or willful misconduct.
7.2 Limitation of Liability
Provider’s liability for non-economic and total damages is capped at the maximum limits permitted under Colorado’s Health Care Availability Act or any successor statute, excluding damages attributable to Provider’s gross negligence or willful and wanton conduct.
7.3 Insurance
Provider shall maintain professional liability insurance meeting or exceeding Colorado statutory minimums. Patient is advised to maintain health-insurance coverage during Treatment.
7.4 Force Majeure
Neither party is liable for delay or failure in performance (other than payment obligations) due to events beyond reasonable control, including declared public-health emergencies.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Agreement and all Disputes are governed by Colorado law, without regard to conflict-of-laws rules.
8.2 Forum Selection
Unless Arbitration Election is made, the parties submit to the exclusive jurisdiction of the state courts located in [County], Colorado (and, if federal jurisdiction exists, the U.S. District Court for the District of Colorado).
8.3 Optional Arbitration
(a) Election. Patient may elect binding arbitration of Disputes by initialing here: ___ (“Arbitration Election”).
(b) Rules. Arbitration shall be administered by the American Arbitration Association under its Health Care Claims Arbitration Rules.
(c) Injunctive Relief. Either party may seek temporary injunctive relief in a court of competent jurisdiction pending the outcome of arbitration.
8.4 Jury Waiver
To the fullest extent permitted by the Colorado Constitution, the parties knowingly and voluntarily waive the right to a trial by jury in any Dispute not resolved by arbitration.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers
Any amendment or waiver must be in a writing signed by both parties. No waiver constitutes a continuing waiver unless expressly stated.
9.2 Assignment
Patient may not assign this Agreement without Provider’s prior written consent. Provider may assign to a successor entity or professional corporation upon notice to Patient.
9.3 Severability
If any provision is held invalid, the remainder remains enforceable, and the invalid provision shall be reformed to the minimum extent necessary to achieve its original intent.
9.4 Entire Agreement
This Agreement, together with Provider’s HIPAA Notice, financial policies, and procedure-specific consent forms, constitutes the entire agreement and supersedes prior oral or written communications on the subject matter.
9.5 Counterparts & Electronic Signatures
This Agreement may be executed in multiple counterparts, each deemed an original. Electronic signatures and records shall have the same force and effect as originals to the fullest extent permitted by the Colorado Uniform Electronic Transactions Act.
10. EXECUTION BLOCK
10.1 Patient / Patient Representative
| Signature | Name & Capacity (e.g., Patient, Parent, POA) | Date | Time |
|---|---|---|---|
10.2 Provider Authorized Signatory
| Signature of Authorized Clinician | Printed Name & Credentials | Date | Time |
|---|---|---|---|
10.3 Witness (if required)
| Signature | Printed Name | Date | Time |
|---|---|---|---|
10.4 Interpreter / Translator (if applicable)
I hereby certify that I accurately translated the Informed Consent Disclosures and the entirety of this Agreement into a language understood by Patient/Patient Representative.
| Signature | Printed Name & Language | Date | Time |
|---|---|---|---|
[// GUIDANCE: Attach or reference any procedure-specific consent sheets, financial policy acknowledgments, and HIPAA forms. Retain executed copies in Patient’s medical record per Colorado retention standards.]