INFORMED CONSENT FOR MEDICAL TREATMENT
(Illinois – Comprehensive Form)
[// GUIDANCE: This template is drafted to comply with Illinois informed-consent standards and common-law disclosure duties. It is structured as a contractual instrument to maximize evidentiary value should capacity, scope of consent, or malpractice claims arise. Bracketed terms must be customized. Remove guidance comments before final execution.]
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 Parties.
This Informed Consent for Medical Treatment (the “Agreement”) is entered into by and between:
a. Patient: [PATIENT LEGAL NAME], residing at [ADDRESS], Date of Birth: [DOB]; and, if applicable,
b. Authorized Representative: [REPRESENTATIVE NAME] acting pursuant to [POWER OF ATTORNEY / GUARDIANSHIP / HEALTH CARE SURROGATE] (collectively, the “Patient”); and
c. Health-Care Provider: [PHYSICIAN OR INSTITUTION LEGAL NAME], an Illinois-licensed [physician/hospital/clinic] (“Provider”).
1.2 Effective Date.
This Agreement is effective as of the date last executed below (the “Effective Date”).
1.3 Governing Law & Venue.
This Agreement is governed by the medical-consent and patient-rights laws of the State of Illinois, without regard to conflict-of-laws rules. Exclusive venue for any court proceeding shall lie in the state courts of [COUNTY], Illinois.
2. DEFINITIONS
For purposes of this Agreement, the following terms have the meanings set forth below. Defined terms appear in initial capital letters throughout.
“Affiliate” – Any entity that controls, is controlled by, or is under common control with the Provider.
“Capacity” – The ability to understand the nature and consequences of the proposed Treatment and to make an informed decision, consistent with Illinois common-law standards and, where applicable, the Illinois Health Care Surrogate Act.
“Complication” – An unintended, yet medically recognized, adverse development that may arise during or after Treatment.
“Disclosed Information” – All oral and written information supplied by Provider concerning Treatment, including the nature, purpose, expected benefits, material risks, alternatives (including the option of no treatment), and anticipated recovery.
“Informed Consent” – A voluntary, knowing authorization by Patient, given with Capacity, based on Disclosed Information.
“Treatment” – The medical, surgical, diagnostic, or therapeutic procedure(s) described in Section 3.2, together with any reasonably related ancillary services.
3. OPERATIVE PROVISIONS
3.1 Consideration.
In consideration of Provider’s agreement to render Treatment, Patient grants the consents and undertakes the obligations set forth herein.
3.2 Description of Treatment.
Patient hereby authorizes Provider to perform the following Treatment:
[DETAILED PROCEDURE DESCRIPTION – include CPT/ICD codes if desired].
3.3 Disclosures Made.
Provider affirms that prior to execution:
a. Material risks and Complications (including [LIST SIGNIFICANT RISKS]) have been disclosed;
b. Reasonable alternatives, their risks, and potential outcomes were discussed;
c. Expected benefits and likelihood of success were explained; and
d. Patient’s questions were answered to Patient’s satisfaction.
3.4 Voluntary Consent & Right to Withdraw.
Patient gives Informed Consent voluntarily and may revoke consent at any time before or during Treatment, subject to Section 6.1 (Costs on Withdrawal).
3.5 Financial Responsibility.
Patient agrees to be financially responsible for all charges not covered by insurance, including deductibles, co-payments, and non-covered services.
[// GUIDANCE: For insured patients, attach Provider’s financial responsibility policy or reference master financial agreement.]
4. REPRESENTATIONS & WARRANTIES
4.1 By Patient.
a. Capacity: Patient represents that Patient possesses Capacity or, if represented, that the Authorized Representative is duly empowered to grant consent.
b. Accurate Information: All medical history provided is true, complete, and accurate to the best of Patient’s knowledge.
4.2 By Provider.
a. Licensure & Competence: Provider warrants that all professionals involved are duly licensed in Illinois and competent to perform the Treatment.
b. Standard of Care: Provider will render Treatment in accordance with the prevailing professional standard of care in Illinois.
4.3 Survival.
The warranties in this Section survive completion of Treatment for the applicable statute-of-limitations period.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants.
a. Compliance: Patient will follow pre- and post-operative instructions and report unexpected symptoms promptly.
b. Cooperation: Patient will furnish complete, accurate information requested by Provider to facilitate safe Treatment.
5.2 Provider Covenants.
Provider will maintain medical records in accordance with Illinois Medical Practice Act requirements and HIPAA.
6. DEFAULT & REMEDIES
6.1 Withdrawal or Revocation.
If Patient withdraws consent after commencement of Treatment, Patient remains liable for (i) services already rendered, and (ii) reasonable costs incurred to safely discontinue Treatment.
6.2 Provider’s Right to Terminate.
Provider may terminate the Physician-Patient relationship upon reasonable notice if Patient materially breaches Section 5.1, subject to continuity-of-care obligations.
6.3 Attorneys’ Fees.
Prevailing party in any action under this Agreement is entitled to reasonable attorneys’ fees and costs, except where prohibited by law.
7. RISK ALLOCATION
7.1 Indemnification (Informed-Consent Protection).
Patient shall indemnify and hold harmless Provider from claims, damages, or expenses arising solely from (i) Patient’s failure to disclose relevant medical history, or (ii) Patient’s non-compliance with post-Treatment instructions, except to the extent caused by Provider’s negligence or willful misconduct.
7.2 Limitation of Liability (Malpractice Limits).
Nothing herein limits Patient’s rights or Provider’s liability for professional negligence beyond any limits expressly permitted by Illinois law. To the extent Illinois law allows contractual limitation of non-economic damages, Provider’s liability for such damages shall not exceed [DOLLAR AMOUNT] per incident.
7.3 Insurance.
Provider represents that it maintains professional liability insurance meeting or exceeding Illinois minimum requirements.
7.4 Force Majeure.
Neither party is liable for delay or failure in performance caused by events beyond reasonable control, excluding payment obligations.
8. DISPUTE RESOLUTION
8.1 Governing Law & Forum.
See Section 1.3.
8.2 Optional Binding Arbitration.
a. Election: At Patient’s sole option, disputes arising from this Agreement may be submitted to binding arbitration under the Commercial Arbitration Rules of the American Arbitration Association.
b. Written Election: Patient must elect arbitration in writing within 90 days after the dispute arises.
c. Costs: Provider will advance filing fees; fees shall be apportioned by the arbitrator.
d. Award: Any award may be entered in a court of competent jurisdiction.
8.3 Jury Trial.
Nothing herein shall be construed as a waiver of Patient’s constitutional right to a jury trial in the absence of a valid arbitration election.
8.4 Injunctive Relief.
Either party may seek injunctive relief solely to (i) enforce HIPAA or confidentiality obligations, or (ii) prevent imminent harm; all other equitable remedies are limited as provided by law.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver.
No amendment or waiver is effective unless in writing and signed by both parties. A waiver on one occasion is not a waiver on subsequent occasions.
9.2 Assignment.
Patient may not assign this Agreement. Provider may assign to an Affiliate or successor by merger, provided professional licensure requirements are met.
9.3 Successors & Assigns.
This Agreement binds and benefits the parties and their permitted successors and assigns.
9.4 Severability.
If any provision is held unenforceable, the remaining provisions remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to render it valid.
9.5 Integration.
This Agreement, together with any attachments expressly incorporated, constitutes the entire understanding regarding Treatment and supersedes all prior oral or written communications.
9.6 Counterparts & Electronic Signatures.
This Agreement may be executed in counterparts, each of which is deemed an original. Electronic signatures and counterpart PDF copies are deemed originals for all purposes.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Informed Consent for Medical Treatment as of the dates written below.
| PATIENT / AUTHORIZED REPRESENTATIVE | DATE |
|---|---|
| _________ | ____ |
| (Signature) | |
| [PRINT NAME & RELATIONSHIP] |
| HEALTH-CARE PROVIDER | DATE |
|---|---|
| _________ | ____ |
| (Authorized Signature) | |
| [NAME & TITLE] | |
| [LICENSE NUMBER] |
[// GUIDANCE:
1. If Illinois law or facility policy requires witness or notarization, insert an additional signature block.
2. Attach the Disclosed Information summary (risk/benefit sheets), financial responsibility policy, and HIPAA Notice of Privacy Practices, and reference them in Section 3.3.]