Patient Consent Form - Treatment (Idaho)

DISCLAIMER (MANDATORY — DO NOT DELETE)
The following document is a model template for educational purposes only and does not constitute legal or medical advice. Use of this template does not create an attorney-client or physician-patient relationship. Idaho informed consent law (I.C. § 39-4501 et seq.) and federal requirements governing informed consent are complex and may have been amended after the "last_updated" date. A qualified Idaho-licensed attorney and the treating clinician must review, customize, and approve this form before clinical use.

PATIENT CONSENT TO TREATMENT

(Idaho — Comprehensive Informed Consent Form Pursuant to I.C. § 39-4501 et seq.)

I. STATUTORY FRAMEWORK AND PURPOSE

This form is intended to document substantial compliance with the Idaho Medical Consent and Natural Death Act, I.C. § 39-4501 et seq., and with the disclosure standard recognized in Sherwood v. Carter, 119 Idaho 246, 805 P.2d 452 (1990), under which the disclosure required is that which would be made by a like physician of good standing practicing in the same community.

Pursuant to I.C. § 39-4505, a consent that is in substantial compliance with the Act and is not obtained through fraud, deception, or misrepresentation of material facts shall be valid notwithstanding minor deviations.

II. CAPACITY DETERMINATION (I.C. § 39-4503)

The treating clinician has assessed the Patient's capacity to consent. Under I.C. § 39-4503, any person who comprehends the need for, the nature of, and the significant risks ordinarily inherent in any contemplated health care services is competent to consent on his or her own behalf.

Capacity Determination (check one):

☐ Patient is an adult (18 years or older) and demonstrates capacity under I.C. § 39-4503.
☐ Patient is a minor but qualifies to consent on his/her own behalf (specify basis below).
☐ Patient lacks capacity; consent is being given by a surrogate decision-maker pursuant to I.C. § 39-4504 (complete Section IV).
☐ Emergency circumstances apply pursuant to I.C. § 39-4503(d) (complete Section V).

Minor Self-Consent Basis (if applicable):

☐ Emancipated minor (court-decreed or by statute).
☐ Minor 15 years of age or older who is married, pregnant, or a parent (I.C. § 39-4503).
☐ Minor 14 years of age or older seeking diagnosis or treatment of a sexually transmitted or reportable communicable disease (I.C. § 39-3801).
☐ Other (specify): [________________________________]

Clinician's brief capacity narrative: [________________________________]

III. DESCRIPTION OF PROPOSED CARE

Diagnosis or working impression: [________________________________]

Proposed procedure / treatment / course of care: [________________________________]

Expected benefits: [________________________________]

Anticipated date(s) of service: [__/__/____]

Site of service: [________________________________]

IV. SURROGATE CONSENT (I.C. § 39-4504)

If the Patient is incapacitated or a minor, consent is given by the following surrogate, in the order of priority recognized by I.C. § 39-4504:

Surrogate name: [________________________________]

Relationship: [________________________________]

Basis for higher-priority surrogate's unavailability (if applicable): [________________________________]

The surrogate represents that he/she is acting consistently with the Patient's known wishes and any advance care planning document, as required by I.C. § 39-4504.

V. EMERGENCY EXCEPTION (I.C. § 39-4503(d))

☐ Not applicable.
☐ Emergency circumstances apply. Treatment is reasonably required to alleviate severe pain or to prevent serious disability or death, and consent could not be obtained from the Patient or a surrogate within the time available. The clinician has documented:

• Nature of the emergency: [________________________________]
• Time of presentation: [__:__ ____ on __/__/____]
• Efforts (if any) to reach a surrogate: [________________________________]

VI. DISCLOSURE OF MATERIAL INFORMATION (Sherwood v. Carter)

The Patient (or surrogate) acknowledges that the treating clinician has disclosed, in language reasonably understandable to the Patient, the following:

1. The Patient's diagnosis or working impression.
2. The nature and purpose of the proposed treatment.
3. The significant risks ordinarily inherent in the treatment, including but not limited to: [________________________________].
4. The probability of success based on the clinician's judgment.
5. Reasonable medical alternatives, including non-treatment, and the risks of each: [________________________________].
6. The anticipated post-treatment course and any limitations.

The Patient (or surrogate) was given an opportunity to ask questions and received responsive answers.

VII. SPECIFIC RISKS DISCLOSED

☐ Bleeding, infection, or adverse reaction to anesthesia.
☐ Allergic reaction or adverse drug interaction.
☐ Damage to adjacent organs or tissues.
☐ Need for additional procedures or hospitalization.
☐ Failure to achieve intended therapeutic result.
☐ Death or permanent disability (where reasonably foreseeable).
☐ Other procedure-specific risks: [________________________________]

VIII. ANESTHESIA, BLOOD PRODUCTS, AND ANCILLARY CONSENTS

☐ Patient consents to administration of anesthesia (general / regional / local — circle one) by a qualified provider.
☐ Patient consents to administration of blood or blood products if medically indicated.
☐ Patient declines blood products on the grounds of [________________________________] and acknowledges the risks of refusal.
☐ Patient consents to participation of medical students, residents, or fellows under appropriate supervision.
☐ Patient consents to photography or recording solely for diagnostic, treatment, or educational purposes.

IX. RIGHT TO REFUSE OR WITHDRAW CONSENT

The Patient (or surrogate) has the right to refuse any proposed treatment and to withdraw consent at any time before or during treatment, subject to clinical safety. Refusal will not affect the Patient's right to ongoing care for unrelated conditions.

The Patient acknowledges that refusal may result in: [________________________________].

X. FINANCIAL DISCLOSURE AND NO FEE-SPLITTING REPRESENTATION

The Provider represents that no portion of any fee for services rendered under this consent has been or will be divided with any person, institution, or corporation in exchange for referral, in compliance with I.C. § 54-1814(8).

Estimated cost of services (good-faith estimate): $[________]

Insurance/payer information: [________________________________]

XI. ADVANCE DIRECTIVES

Does the Patient have an executed Living Will / Durable Power of Attorney for Health Care under the Idaho Medical Consent and Natural Death Act?

☐ Yes — copy attached and reviewed.
☐ No.
☐ Patient declines to disclose.

XII. ACKNOWLEDGMENT AND EXECUTION

I have read (or had read to me) this form. I have had an opportunity to ask questions, and my questions have been answered to my satisfaction. I consent to the treatment described above.

Language of communication: [________________________________]

Interpreter credentials (if used): [________________________________]

XIII. CLINICIAN ATTESTATION

I, the undersigned treating clinician, attest that I personally explained to the Patient (or surrogate) the information set forth in Sections III, VI, and VII; that I assessed capacity in accordance with I.C. § 39-4503; that I obtained consent in substantial compliance with I.C. § 39-4501 et seq.; and that the disclosures made satisfy the standard recognized in Sherwood v. Carter, 119 Idaho 246 (1990).

Clinician signature: [____________________]
Date / Time: [__/__/____] [__:__ ____]

SOURCES AND REFERENCES

• Idaho Code Title 39, Chapter 45 (Medical Consent and Natural Death Act)
• Idaho Code § 39-3801 (minor consent for communicable disease)
• Idaho Code § 54-1814 (grounds for medical discipline)
• Sherwood v. Carter, 119 Idaho 246, 805 P.2d 452 (1990)
• Idaho Board of Medicine guidance and Idaho Administrative Code, IDAPA 22 (Bureau of Occupational Licenses — Medicine)