TREATMENT CONSENT AND INFORMED ACKNOWLEDGMENT
[// GUIDANCE: Replace bracketed “PLACEHOLDER” language with client-specific information before use.]
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. Treatment Consent and Informed Acknowledgment (the “Consent”).
1.2 Parties.
(a) “[PATIENT LEGAL NAME]”, an individual (“Patient”); and
(b) “[PROVIDER LEGAL NAME]”, a licensed healthcare provider under the laws of the State of Florida (“Provider”).
1.3 Recitals.
A. Provider has recommended that Patient undergo the medical treatment or procedure described herein (the “Treatment”).
B. Patient desires to provide informed consent to the Treatment pursuant to Fla. Stat. § 766.103 (2023) and applicable federal law.
C. The parties therefore enter into this Consent as of the Effective Date defined below.
1.4 Effective Date. The later of (i) the date signed by Patient (or Patient Representative) or (ii) the date signed by Provider (the “Effective Date”).
1.5 Governing Law & Venue. This Consent is governed by the medical consent laws of the State of Florida (“State Medical Law”), and any action arising hereunder shall be filed exclusively in the state courts sitting in [COUNTY], Florida, unless the parties have elected binding arbitration under Section 8.3.
2. DEFINITIONS
For purposes of this Consent, the following capitalized terms shall have the meanings set forth below:
“Alternatives” means reasonable alternative treatments, procedures, or courses of action, including the option of no treatment, disclosed to Patient pursuant to Section 3.2.
“Authorized Health Information” means the protected health information that Patient authorizes Provider to disclose or obtain under Section 3.6.
“Capacity” means an individual’s ability to understand the nature, risks, benefits, and Alternatives of the Treatment and to make a voluntary healthcare decision.
“Complication” means an unanticipated yet medically recognized adverse outcome associated with the Treatment.
“Material Risk” means any risk to Patient that a reasonably prudent patient in similar circumstances would consider significant in deciding whether to undergo the Treatment.
“Patient Representative” means a person authorized under Florida law (including but not limited to a health care surrogate, guardian, or durable power of attorney holder) to act on behalf of the Patient if Patient lacks Capacity.
“Treatment” means the specific medical procedure(s), course(s) of treatment, or regimen(s) described in Section 3.1.
3. OPERATIVE PROVISIONS
3.1 Description of Treatment.
Provider shall administer or perform the following Treatment:
[DETAILED TREATMENT DESCRIPTION, INCLUDING MEDICAL TERMINOLOGY & CPT/HCPCS CODES IF KNOWN].
3.2 Disclosure of Material Information.
(a) Risks & Complications. Provider has explained and Patient acknowledges understanding of the Material Risks and potential Complications, including but not limited to:
• [SPECIFIC RISK 1]
• [SPECIFIC RISK 2]
• [SPECIFIC RISK 3]
(b) Benefits & Goals. Provider has explained the intended benefits and probable outcome of the Treatment.
(c) Alternatives. Provider has explained the Alternatives, including the option to refuse Treatment and the reasonably foreseeable consequences of refusal.
3.3 Voluntary Consent.
Patient affirms that the decision to proceed is voluntary and made without coercion. Patient may withdraw consent at any time prior to or during Treatment without jeopardizing future care.
3.4 Capacity & Acknowledgment.
Patient represents that he/she has Capacity. If Patient lacks Capacity, the Patient Representative executing this Consent represents authority to act on Patient’s behalf.
3.5 Financial Responsibility.
Patient agrees to be financially responsible for all charges associated with the Treatment, subject to applicable insurance payments and statutory limitations.
3.6 Authorization to Release/Obtain Health Information.
Patient authorizes Provider to release and obtain Authorized Health Information as necessary for the coordination of care, billing, and compliance with legal reporting obligations.
3.7 Post-Treatment Instructions & Follow-Up.
Patient agrees to comply with all post-Treatment instructions provided by Provider and to attend recommended follow-up appointments.
3.8 Withdrawal of Consent.
If Patient withdraws consent after Treatment commences, Provider may discontinue the Treatment when medically safe to do so.
4. REPRESENTATIONS & WARRANTIES
4.1 Provider Representations.
(a) Licensure. Provider holds all licenses, certifications, and permits required to perform the Treatment in Florida.
(b) Standard of Care. Provider will perform the Treatment in accordance with the prevailing professional standard of care.
4.2 Patient Representations.
(a) Complete Disclosure. Patient has fully and accurately disclosed medical history, allergies, medications, and other relevant information.
(b) Questions Answered. Patient has had the opportunity to ask questions, and such questions have been answered to Patient’s satisfaction.
4.3 Survival. The representations and warranties in this Section survive completion of the Treatment.
5. COVENANTS & RESTRICTIONS
5.1 Provider Covenants.
(a) Compliance. Provider will comply with all applicable laws, regulations, and ethical standards, including HIPAA and State Medical Law.
(b) Documentation. Provider will maintain accurate medical records relating to the Treatment.
5.2 Patient Covenants.
(a) Cooperation. Patient will cooperate with Provider during Treatment and post-Treatment care.
(b) Notification. Patient will promptly notify Provider of any adverse reactions or unexpected changes in condition.
6. DEFAULT & REMEDIES
6.1 Patient Default.
Failure by Patient to comply with Section 5.2 may relieve Provider of responsibility for adverse outcomes directly resulting from such non-compliance.
6.2 Provider Default.
Failure by Provider to perform in accordance with Section 4.1(b) constitutes a breach, subject to applicable malpractice remedies under Florida law.
6.3 Notice & Cure.
The non-breaching party shall deliver written notice of any alleged breach and afford the breaching party [30] days to cure, except where immediate action is medically necessary.
6.4 Attorneys’ Fees.
In any action to enforce this Consent, the prevailing party is entitled to reasonable attorneys’ fees and costs.
7. RISK ALLOCATION
7.1 Indemnification by Patient.
Patient (or Patient Representative) shall indemnify and hold harmless Provider from losses arising out of Patient’s material misrepresentation or failure to disclose information material to the Treatment (“Informed-Consent Protection”).
7.2 Limitation of Liability.
Provider’s liability for noneconomic damages shall not exceed the statutory limitations applicable to medical malpractice claims in Florida (“Malpractice Limits”), unless such limits are held unenforceable by a court of competent jurisdiction.
7.3 Insurance.
Provider maintains professional liability insurance meeting or exceeding statutory minimums.
7.4 Force Majeure.
Neither party shall be liable for delay or failure in performance caused by events beyond reasonable control, provided that medical emergencies are managed in accordance with the applicable standard of care.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Consent is governed by the laws of the State of Florida without regard to conflict-of-law principles.
8.2 Forum Selection. Unless arbitration is elected, exclusive jurisdiction and venue lie in the state courts located in [COUNTY], Florida.
8.3 Arbitration Election.
[CHECK ONE]
☐ The parties elect to submit any dispute to binding arbitration administered by the American Arbitration Association under its Healthcare Arbitration Rules.
☐ The parties do NOT elect arbitration and will resolve disputes in state court.
8.4 Jury Trial Waiver.
To the fullest extent permitted by the Florida Constitution and applicable law, the parties waive the right to trial by jury. If such waiver is deemed unenforceable, this Section shall be severed.
8.5 Injunctive Relief.
Either party may seek provisional or injunctive relief solely to prevent imminent and irreparable harm related to the confidentiality of medical records or continuity of medical care.
9. GENERAL PROVISIONS
9.1 Amendments; Waivers. Any amendment must be in writing and signed by both parties. A waiver of any term is not a waiver of any other term.
9.2 Assignment. Patient may not assign rights or delegate duties under this Consent without Provider’s written consent. Provider may assign this Consent to a successor practice entity upon written notice to Patient.
9.3 Successors & Assigns. This Consent binds and benefits the parties and their respective successors and permitted assigns.
9.4 Severability. If any provision is held invalid or unenforceable, the remaining provisions remain in full force, and the invalid provision shall be interpreted to fulfill its intended purpose to the maximum extent permitted.
9.5 Entire Agreement. This Consent constitutes the entire agreement between the parties concerning the Treatment and supersedes all prior discussions, understandings, or documents.
9.6 Counterparts; Electronic Signatures. This Consent may be executed in counterparts, each of which is deemed an original. Electronic signatures and facsimile transmissions are as effective as originals.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Consent as of the Effective Date.
PATIENT / PATIENT REPRESENTATIVE
Signature: ____
Print Name: ____
Capacity (if Representative): _________
Date: ______
HEALTHCARE PROVIDER
Signature: ____
Print Name: ____
Title/License No.: ___
Date: ______
[Notary acknowledgment if required by facility policy or if Patient Representative is signing under durable power of attorney.]
[// GUIDANCE:
1. Attach any required Disclosure Schedules detailing specific risks or alternative treatments if the Treatment is complex.
2. Retain this Consent in the patient’s chart for the period mandated by Fla. Admin. Code & HIPAA retention rules.
3. For minors or incapacitated adults, ensure compliance with Fla. Stat. ch. 744 and ch. 765 capacity and surrogate provisions.]