Kansas Patient Consent Form for Treatment

KANSAS PATIENT CONSENT TO TREATMENT

Provider Entity: [LEGAL NAME OF HOSPITAL / CLINIC / PHYSICIAN GROUP] ("Provider")
Treating Clinician: [NAME, M.D./D.O., KANSAS LICENSE NO. _________]
Patient: [LEGAL NAME] ("Patient")
Date of Birth: [__/__/____]
Medical Record No.: [____________]
Authorized Representative (if any): [NAME] / Relationship: [____________]
Effective Date: [__/__/____]

I. PURPOSE AND GOVERNING LAW

A. This document records the informed consent of Patient (or Representative) to the medical treatment, procedure, or service described in Section III ("Treatment"), in compliance with the Kansas common-law informed-consent doctrine articulated in Funke v. Fieldman, 212 Kan. 524, 516 P.2d 999 (1973).

B. Kansas Disclosure Standard. Kansas applies the reasonable physician (professional) standard of disclosure - the treating clinician must disclose those risks, benefits, and alternatives that a reasonable medical practitioner would disclose under the same or similar circumstances. Kansas does not apply the reasonable-patient (materiality) standard used in jurisdictions such as California. Expert testimony is generally required to establish the scope of disclosure in a malpractice action premised on lack of informed consent.

C. This Agreement is governed by Kansas law, including the Kansas Healing Arts Act, K.S.A. 65-2801 et seq., the Kansas Natural Death Act, K.S.A. 65-28,101 et seq., the Durable Power of Attorney for Health Care Decisions Act, K.S.A. 58-625 et seq., and applicable federal law (HIPAA, 42 C.F.R. Part 2 where relevant).

II. DEFINITIONS

III. DESCRIPTION OF PROPOSED TREATMENT

Diagnosis / Indication: [____________]

Proposed Treatment / Procedure: [____________]

Anticipated Date(s) of Treatment: [__/__/____]

Site / Anatomical Location (if applicable): [____________]

Anesthesia / Sedation Type (if applicable): [____________]

IV. DISCLOSURE OF RISKS, BENEFITS, AND ALTERNATIVES (Funke Disclosure)

A. Material Risks Disclosed. The treating clinician has disclosed the following risks that a reasonable medical practitioner would disclose under the same or similar circumstances:

☐ Bleeding / hemorrhage
☐ Infection (local or systemic)
☐ Adverse reaction to anesthesia or medication
☐ Damage to adjacent nerves, vessels, organs, or tissue
☐ Need for additional / unanticipated procedures
☐ Blood clots, embolism, stroke
☐ Scarring, chronic pain, loss of function
☐ Cardiac, pulmonary, or renal complications
☐ Death
☐ Other procedure-specific risks: [____________]

B. Benefits. The reasonably anticipated benefits of Treatment are: [____________]

C. Alternatives. Reasonable alternatives, including the alternative of no treatment, were disclosed: [____________]

D. Likelihood of Success. [____________]

E. No Guarantee. Patient acknowledges that no guarantee or assurance of any specific outcome has been made.

V. CAPACITY AND CONSENT BY ADULTS

A. Patient represents that Patient is 18 years of age or older (K.S.A. 38-101) and has Capacity to consent.

B. Surrogate Decision-Making. If Patient lacks Capacity:

☐ Agent acting under Durable Power of Attorney for Health Care Decisions (K.S.A. 58-625 et seq.) - copy attached.
☐ Court-appointed guardian (K.S.A. 59-3075 et seq.) - letters of guardianship attached.
☐ Other lawful surrogate: [____________]

C. Advance Directives. Patient has executed (check all that apply):
☐ Declaration under the Kansas Natural Death Act (K.S.A. 65-28,103) (living will)
☐ Durable Power of Attorney for Health Care Decisions (K.S.A. 58-625)
☐ Do-Not-Resuscitate / TPOPP order
☐ None

VI. CONSENT INVOLVING MINORS

A. General Rule. Consent for a minor (under 18) is generally given by a parent or legal guardian.

B. Minor 16 or Older - K.S.A. 38-123b. A minor 16 years of age or older may consent to hospital, medical, or surgical treatment when no parent or guardian is immediately available; such consent is not subject to disaffirmance because of minority.

C. Specific-Purpose Minor Consent (no minimum age unless noted).

D. Mature Minor Doctrine. Where statutory consent is unavailable, the clinician may rely on the Younts mature-minor doctrine after assessing the minor's intellectual capacity, experience, and ability to understand the nature and consequences of the Treatment. Reliance on the doctrine should be documented in the chart.

VII. EMERGENCY EXCEPTION

In a bona-fide Emergency where the Patient lacks Capacity and no Surrogate is reasonably available, Treatment necessary to preserve life, limb, or bodily function may proceed without prior written consent, consistent with Kansas common law and K.S.A. 65-2891. The basis for invoking the emergency exception shall be contemporaneously documented in the medical record.

VIII. SPECIFIC ACKNOWLEDGMENTS

Patient (or Representative) initials each item:

[____] I have had an opportunity to ask questions about the Treatment, and my questions have been answered to my satisfaction.

[____] I understand that the practice of medicine is not an exact science, and no guarantee of results has been made.

[____] I authorize the treating clinician and such assistants, residents, fellows, and consultants as the clinician may select to perform the Treatment, including the administration of anesthesia.

[____] I authorize unanticipated procedures the clinician deems medically necessary in the exercise of professional judgment during the Treatment.

[____] I consent to the disposal, retention, examination, or use for medical/scientific/educational purposes of any tissue, organ, or specimen removed during the Treatment, subject to applicable law.

[____] I consent to photography/imaging for medical record, identification, or educational purposes (de-identified).

[____] I have been informed of my right to refuse Treatment.

IX. PRIVACY AND HIPAA AUTHORIZATION

Patient acknowledges receipt of Provider's Notice of Privacy Practices and consents to use and disclosure of PHI for treatment, payment, and health-care-operations purposes consistent with 45 C.F.R. §§ 164.502, 164.506, and applicable Kansas law.

X. RIGHT TO REVOKE / WITHDRAW CONSENT

Patient may revoke this consent at any time prior to the Treatment by written or verbal notice to the treating clinician. Revocation does not apply to actions taken in reliance on this consent prior to revocation.

XI. INTERPRETER / LANGUAGE ASSISTANCE

☐ Treatment, risks, benefits, and alternatives were discussed in English.
☐ A qualified interpreter assisted: Name [____________] / Language [____________] / Method (in-person/telephonic/video) [____________].

XII. EXECUTION

XIII. SOURCES AND REFERENCES

• Funke v. Fieldman, 212 Kan. 524, 516 P.2d 999 (1973)
• Younts v. St. Francis Hospital & School of Nursing, 205 Kan. 292, 469 P.2d 330 (1970)
• Kansas Natural Death Act, K.S.A. 65-28,101 to 65-28,109
• Durable Power of Attorney for Health Care Decisions Act, K.S.A. 58-625 to 58-632
• K.S.A. 38-101 (age of majority); K.S.A. 38-123b (minor 16+ consent)
• K.S.A. 65-2891, 65-2892, 65-2892a (specific minor consent statutes)
• Kansas Healing Arts Act, K.S.A. 65-2801 et seq.
• HIPAA Privacy Rule, 45 C.F.R. Parts 160, 164

END OF FORM