Indiana Patient Informed Consent for Medical Treatment

INDIANA PATIENT INFORMED CONSENT FOR MEDICAL TREATMENT

Facility / Provider: [________________________________]
Provider NPI: [________________________________]
Patient Name: [________________________________]
Date of Birth: [__/__/____]
Medical Record No.: [________________________________]
Date of Consent: [__/__/____] Time: [____:____ ☐ AM ☐ PM]

1. IDENTIFICATION OF PATIENT AND PROVIDER

2. NATURE AND PURPOSE OF PROPOSED TREATMENT

The provider has explained, in language I understand, the following:

• Diagnosis or condition requiring treatment: [________________________________]
• Description of the proposed procedure or treatment: [________________________________]
• Purpose and anticipated benefits: [________________________________]
• Whether the procedure is considered experimental, investigational, or non-conventional under IC § 25-22.5-1-2.1: ☐ No ☐ Yes — additional written disclosure attached

3. MATERIAL RISKS AND COMPLICATIONS

The provider has disclosed the material risks, complications, and side effects of the proposed treatment that a reasonably prudent physician practicing in Indiana would disclose, including without limitation:

• ☐ Bleeding, infection, or adverse reaction to medication or anesthesia
• ☐ Pain, scarring, or impaired function of treated area
• ☐ Damage to nerves, blood vessels, or adjacent organs
• ☐ Cardiac, respiratory, or thromboembolic events
• ☐ Need for additional or unanticipated procedures
• ☐ Hospitalization, transfusion, or extended recovery
• ☐ Disability, permanent injury, or death
• ☐ Procedure-specific risks: [________________________________]

Estimated likelihood of significant complication, where known: [________________________________]

4. ALTERNATIVES TO PROPOSED TREATMENT

5. ANESTHESIA AND ADDITIONAL PROVIDERS

• ☐ Local anesthesia ☐ Regional / nerve block ☐ Monitored anesthesia care ☐ General anesthesia
• ☐ I consent to administration of anesthesia by a qualified anesthesia provider, and to such additional anesthetic measures as may be medically indicated.
• ☐ I understand that residents, fellows, students, surgical assistants, or other authorized personnel may participate under appropriate supervision.

6. BLOOD PRODUCTS, TISSUE, AND DISPOSAL

• ☐ I consent to administration of blood or blood products if medically indicated.
• ☐ I decline blood products and have discussed alternatives and risks with my provider.
• ☐ I consent to disposal or pathologic examination of removed tissue, organs, or specimens consistent with applicable law and facility policy.

7. PHOTOGRAPHY, RECORDING, AND OBSERVERS

• ☐ I consent to clinical photography or video recording for the medical record only.
• ☐ I consent to use of de-identified images for education or quality improvement.
• ☐ I do not consent to recording or observers beyond required clinical staff.

8. FINANCIAL DISCLOSURE

• ☐ I have received an estimate of charges or have been advised that an estimate is available on request.
• ☐ I understand my insurance may not cover all charges and that I may be responsible for amounts not paid by my plan.

9. CAPACITY AND VOLUNTARINESS (IC § 16-36-1)

I represent that I:

• ☐ Am at least 18 years of age, or am otherwise authorized to consent under IC § 16-36-1-3 (emancipated; at least 14 and living apart and managing my own affairs; married; or in active military service);
• ☐ Have sufficient capacity to understand the nature and consequences of the proposed treatment;
• ☐ Have had the opportunity to ask questions, and all questions have been answered to my satisfaction;
• ☐ Am giving consent voluntarily and without coercion.

10. CONSENT BY MINOR OR INCAPACITATED PATIENT

Patient is a minor or lacks capacity. Authorized representative completes below:

11. EMERGENCY / IMPLIED CONSENT

If signed under emergency / implied-consent conditions:

• Nature of emergency: [________________________________]
• Patient's incapacity: [________________________________]
• Attempts made to contact authorized representative (with times): [________________________________]
• Treating physician determination that delay would seriously endanger life or health: ☐ Documented in chart

12. RIGHT TO REFUSE OR WITHDRAW CONSENT

I understand that I (or my authorized representative) may refuse the proposed treatment or withdraw this consent at any time before the procedure begins, and that withdrawal will not affect my right to other appropriate care.

13. ACKNOWLEDGMENT AND SIGNATURES

By signing below, I acknowledge that the provider has explained the matters above; that I have read (or had read to me) and understand this consent form; and that I authorize the proposed treatment and any reasonably necessary related care.

14. PROVIDER ATTESTATION

I have personally explained to the patient (or authorized representative) the nature of the condition, the proposed treatment, its material risks and benefits, and reasonable alternatives, consistent with the standard of disclosure recognized in Indiana under Culbertson v. Mernitz, 602 N.E.2d 98 (Ind. 1992), and applicable provisions of IC § 34-18-12 and IC § 16-36-1. I answered the patient's questions before consent was given.

SOURCES AND REFERENCES

• Indiana Medical Malpractice Act, IC § 34-18 (informed consent provisions, IC § 34-18-12)
• Indiana Health Care Consent Act, IC § 16-36-1 (including IC § 16-36-1-3 minor consent and IC § 16-36-1-5 surrogate authority)
• Indiana Medical Practice Act, IC § 25-22.5 (including IC § 25-22.5-1-2.1 experimental treatment disclosures)
• Confidential minor services: IC § 25-1-9.5 (verify chapter and current age threshold)
• Culbertson v. Mernitz, 602 N.E.2d 98 (Ind. 1992) (reasonable physician disclosure standard — verify currency)
• Indiana Medical Licensing Board guidance and 844 IAC (administrative rules)