Louisiana Informed Consent for Medical Treatment

LOUISIANA INFORMED CONSENT FOR MEDICAL TREATMENT

PART 1 — PATIENT, PROVIDER, AND FACILITY IDENTIFICATION

PART 2 — PROCEDURE OR TREATMENT

Procedure / Treatment Recommended: [________________________________]

Indication / Diagnosis: [________________________________]

Anticipated Date of Procedure: [__/__/____]

LMDP Classification (check one):

• ☐ List A — Procedure listed by the Louisiana Medical Disclosure Panel as requiring written disclosure. The LMDP-approved disclosure form for this procedure is attached as Exhibit A and incorporated by reference. Use of this form is intended to invoke the rebuttable presumption of effective consent under La. R.S. § 40:1157.1(C).
• ☐ List B — Procedure listed by the LMDP as requiring no disclosure.
• ☐ Not Listed — Procedure is not on either LMDP list. Disclosure is governed by the reasonable-patient standard under Louisiana common law and La. R.S. § 40:1157.1(A).
• ☐ Emergency Exception — Disclosure is not feasible under La. R.S. § 40:1159.6 because [________________________________].

PART 3 — DISCLOSURE OF RISKS, HAZARDS, AND ALTERNATIVES

I, the patient (or authorized representative), acknowledge that the treating physician or designee has explained, in language I understand, each of the following:

• ☐ The nature of the proposed procedure or treatment.
• ☐ The medical reason(s) the procedure or treatment is recommended.
• ☐ The known material risks and hazards reasonably foreseeable from the procedure, including but not limited to: [________________________________].
• ☐ The probable consequences if the procedure or treatment is not performed.
• ☐ Reasonable medical or surgical alternatives, including non-treatment, and the risks and benefits of each: [________________________________].
• ☐ The likelihood of success and any material limitations on the expected outcome.
• ☐ The identity of the physician(s) who will perform or substantially participate in the procedure, including any resident, fellow, or non-physician practitioner: [________________________________].
• ☐ Any anticipated use of blood products, anesthesia, implants, or investigational devices.
• ☐ The right to ask questions and to refuse or withdraw consent at any time before the procedure begins.

Specific risks disclosed for this procedure (use LMDP form language verbatim where applicable):

[________________________________]
[________________________________]
[________________________________]

PART 4 — ANESTHESIA, BLOOD PRODUCTS, AND ANCILLARY CONSENTS

PART 5 — FINANCIAL AND BILLING DISCLOSURE

• ☐ I have been informed that other providers (assistant surgeon, anesthesiologist, pathologist, radiologist, facility) may bill separately and may or may not be in-network with my insurer.
• ☐ I have received estimated charges or have been directed to the facility business office for an estimate.

PART 6 — CAPACITY AND AUTHORITY TO CONSENT

Adult patient with capacity — La. R.S. § 40:1159.1 et seq.:

• ☐ I am at least 18 years of age (La. Civ. Code art. 29) and have decisional capacity. I sign on my own behalf.

Authorized representative — complete one of the following:

• ☐ Curator / Tutor appointed by court order dated [__/__/____], [_____ Parish].
• ☐ Healthcare power of attorney / Mandate under La. C.C. art. 2989 et seq., dated [__/__/____].
• ☐ Statutory surrogate under La. R.S. § 40:1159.4 (priority order: spouse, adult child, parent, sibling, other ascending or descending relative, friend with knowledge of patient's values).
• ☐ Parent / Legal guardian of an unemancipated minor, where minor consent does not apply.

Minor consent — Louisiana exceptions:

• ☐ Minor's own consent for general medical care under La. R.S. § 40:1079.1 (minor who believes themselves afflicted with illness or disease may consent without parental involvement; physician may, but is not required to, notify parent).
• ☐ Minor's consent for sexually transmitted disease / reproductive health — verify current statute citation; historically La. R.S. § 40:1095 (now recodified). Consult counsel for current section.
• ☐ Minor's consent for substance abuse treatment under La. R.S. § 40:1098.1 (and related provisions).
• ☐ Emancipated minor under La. Civ. Code art. 366 et seq. (judicial or marital emancipation) — attach proof.

PART 7 — ADVANCE DIRECTIVE AND LIFE-SUSTAINING PROCEDURES

• ☐ I have executed a Louisiana Declaration concerning life-sustaining procedures (Living Will) under La. R.S. § 40:1151.1 et seq. (formerly § 40:1299.58.1 et seq.). Copy ☐ on file ☐ attached.
• ☐ I have executed a Healthcare Power of Attorney / Mandate. Copy ☐ on file ☐ attached.
• ☐ I have not executed an advance directive and have been offered information regarding my right to do so.

PART 8 — INTERPRETER / LANGUAGE ACCESS

• ☐ Form provided and explained in English.
• ☐ Qualified interpreter used: Language [__________]; Interpreter Name [__________]; Method ☐ in-person ☐ telephonic ☐ video.
• ☐ Patient declined interpreter services.

PART 9 — PATIENT ACKNOWLEDGMENT AND SIGNATURES

By signing below, I acknowledge that I have read this form (or had it read to me), I have had the opportunity to ask questions, my questions have been answered to my satisfaction, and I voluntarily consent to the procedure or treatment described above.

PART 10 — WITHDRAWAL OF CONSENT

I understand I may withdraw consent at any time before the procedure begins by notifying any member of the treatment team in writing or orally. Withdrawal will not affect my right to receive medical care.

Patient signature on withdrawal: [________________________________] Date: [__/__/____]

EXHIBIT A — LMDP-APPROVED DISCLOSURE FORM

[ATTACH LMDP FORM]

SOURCES AND REFERENCES

• La. R.S. § 40:1157.1 — Consent to medical treatment; methods of obtaining consent.
• La. R.S. § 40:1157.2 — Louisiana Medical Disclosure Panel.
• La. R.S. § 40:1159.1 et seq. — Surgical or medical treatment consent.
• La. R.S. § 40:1151.1 et seq. — Declaration concerning life-sustaining procedures.
• La. R.S. § 40:1079.1 — Minor consent (formerly § 40:1095).
• La. R.S. § 40:1098.1 et seq. — Minor consent for substance abuse treatment.
• La. Civ. Code art. 29 — Age of majority.
• Hondroulis v. Schuhmacher, 553 So. 2d 398 (La. 1988) — reasonable-patient standard.
• Louisiana Department of Health, Louisiana Medical Disclosure Panel — current List A and List B.