Patient Consent Form - Treatment

PATIENT CONSENT TO MEDICAL TREATMENT

(Maryland – Comprehensive Form)

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1.1 Title
Patient Consent to Medical Treatment and Related Procedures (the “Agreement”).

1.2 Parties
This Agreement is entered into by and between:
(a) [PRACTICE NAME], a [Maryland entity type] with a principal place of business at [ADDRESS] (“Provider”); and
(b) [PATIENT NAME], born [DOB], residing at [ADDRESS], or the Patient’s Authorized Representative identified below (“Patient”).

1.3 Recitals
A. Provider has recommended that Patient undergo the medical treatment(s), procedure(s), and/or course(s) of care described in Exhibit A (collectively, the “Treatment”).
B. Maryland law requires voluntary, knowing, and competent informed consent prior to the provision of any non-emergency Treatment.
C. Patient desires to receive the Treatment and hereby provides informed consent in accordance with this Agreement.

1.4 Effective Date
This Agreement is effective as of the date of Patient’s (or Authorized Representative’s) signature (“Effective Date”).

1.5 Governing Law & Jurisdiction
This Agreement shall be governed by the medical-practice and other applicable laws of the State of Maryland (“Governing Law”).

II. DEFINITIONS

For ease of reference, capitalized terms used herein have the following meanings:

“Authorized Representative” means an individual empowered under a valid advance directive, power of attorney, court order, or the Maryland Health Care Decisions Act to act on Patient’s behalf where Patient lacks Capacity.

“Capacity” means the ability to understand the nature, consequences, and risks of the proposed Treatment and to make and communicate a voluntary decision.

“Emergency” means a situation in which immediate Treatment is necessary to prevent serious harm or death and obtaining prior consent is impracticable.

“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (45 C.F.R. Parts 160 & 164).

“Malpractice Cap” means the statutory limitation on non-economic damages applicable to medical malpractice claims under Md. Code Ann., Cts. & Jud. Proc. § 3-2A-09 (West, current through 2025 Sess.).

“Treatment Plan” means the description of recommended procedures, alternatives, material risks, and anticipated benefits set out in Exhibit A, as may be amended by written addendum.

III. OPERATIVE PROVISIONS

3.1 Grant of Consent
Subject to the terms of this Agreement, Patient hereby:
(a) Acknowledges having received, read, and understood the Treatment Plan;
(b) Grants informed consent for Provider to perform the Treatment, employ necessary ancillary procedures (including anesthesia, radiology, and laboratory services), and utilize appropriate clinical personnel; and
(c) Authorizes Provider to administer additional or alternative procedures reasonably necessary in the Provider’s professional judgment to address unanticipated conditions discovered during Treatment, provided such procedures are within the standard of care and consistent with Maryland law.

3.2 Informed Consent Disclosures
Provider affirms that prior to execution, Patient was advised verbally and in writing of:
(i) The diagnosis and purpose of the Treatment;
(ii) The reasonably foreseeable material risks and expected benefits;
(iii) Viable alternative treatments (including no treatment) and their risks/benefits;
(iv) The probability of success and potential complications;
(v) Estimated recovery time and post-Treatment limitations; and
(vi) The right to withdraw consent at any time prior to material completion of the Treatment.

3.3 Financial Responsibility
(a) Patient remains responsible for all charges not covered by insurance, including co-payments, deductibles, and non-covered services.
(b) Provider will make good-faith efforts to verify insurance benefits but makes no guarantee of coverage or payment.

3.4 Conditions Precedent
Provider’s obligation to render Treatment is conditioned upon:
(a) Verification of Patient’s Capacity or, where applicable, the legal authority of the Authorized Representative;
(b) Completion of all pre-operative evaluations and clearance; and
(c) Receipt of any required deposits or insurance authorizations.

3.5 Right of Withdrawal
Patient may revoke this Consent at any time in writing, except where withdrawal would threaten Patient’s life or health and Patient is unable to provide alternative instructions. Provider shall use best efforts to honor withdrawal promptly and safely.

IV. REPRESENTATIONS & WARRANTIES

4.1 Patient Representations
Patient (or Authorized Representative) represents and warrants that:
(a) Patient has Capacity or, if incapacitated, the signer is duly authorized to consent;
(b) All medical history provided is accurate and complete;
(c) Patient is not relying on any oral statement inconsistent with the written disclosures herein; and
(d) Patient understands English or has received a translation adequate to ensure comprehension.

4.2 Provider Representations
Provider represents and warrants that:
(a) Provider and all clinical staff assigned to Treatment hold and will maintain all licenses, certifications, and permits required by Maryland and federal law;
(b) Treatment will be rendered in accordance with the prevailing professional standard of care; and
(c) Provider maintains professional liability insurance meeting or exceeding statutory minimums.

4.3 Survival
All representations and warranties survive completion of Treatment and any termination of this Agreement, subject to applicable statutes of limitation.

V. COVENANTS & RESTRICTIONS

5.1 Patient Covenants
(a) Compliance: Patient shall comply with all pre- and post-Treatment instructions.
(b) Disclosure: Patient shall promptly inform Provider of any material change in health status or medications.
(c) Payment: Patient shall pay all amounts due within thirty (30) days of invoice absent good-faith dispute.

5.2 Provider Covenants
(a) Confidentiality: Provider shall safeguard Protected Health Information (“PHI”) in compliance with HIPAA and Maryland confidentiality laws.
(b) Notice of Material Events: Provider shall notify Patient of any material adverse event or significant deviation from the Treatment Plan as soon as practicable.

5.3 Prohibited Conduct
Neither party shall record Treatment without prior written consent, except as required by law.

VI. DEFAULT & REMEDIES

6.1 Events of Patient Default
(a) Material breach of Section 5.1;
(b) Failure to pay undisputed amounts when due; or
(c) Intentional misrepresentation of medical information.

6.2 Provider Remedies
Upon Patient default, Provider may:
(i) Suspend non-emergency Treatment until cure;
(ii) Demand immediate payment of outstanding balances; and
(iii) Pursue collection costs, including reasonable attorneys’ fees.

6.3 Events of Provider Default
Material deviation from the standard of care, fraud, or willful misconduct.

6.4 Patient Remedies
Patient may terminate this Agreement and pursue remedies available under Governing Law, subject to Section VII (Risk Allocation).

6.5 Cure Period
Except for emergencies, the non-defaulting party shall provide written notice and a ten (10) day opportunity to cure before exercising remedies.

VII. RISK ALLOCATION

7.1 Indemnification by Patient
Patient shall indemnify, defend, and hold harmless Provider and its personnel from any loss arising from (a) Patient’s breach of Section 5.1, or (b) Patient’s failure to disclose material medical information, except to the extent caused by Provider’s negligence or wrongdoing.

7.2 Indemnification by Provider
Provider shall indemnify and hold harmless Patient against any loss finally adjudicated to have resulted from Provider’s gross negligence or willful misconduct.

7.3 Limitation of Liability
(a) Non-Economic Damages: Any recovery for non-economic damages arising out of the Treatment shall be subject to the Malpractice Cap.
(b) Exclusion of Consequential Damages: Neither party shall be liable for indirect, incidental, or consequential damages, except to the extent such exclusion is unenforceable under Maryland law.

7.4 Insurance
Each party shall maintain any insurance mandated by law or reasonably appropriate to its obligations under this Agreement.

7.5 Force Majeure
Neither party shall be liable for delay or failure in performance caused by events beyond its reasonable control, including but not limited to natural disasters, acts of terrorism, or governmental orders, except for payment obligations.

VIII. DISPUTE RESOLUTION

8.1 Good-Faith Negotiation
The parties shall first attempt in good faith to resolve any dispute arising under this Agreement within thirty (30) days of written notice.

8.2 Optional Arbitration
[SELECT ONE]
☐ Arbitration Elected – Any dispute not resolved by negotiation shall be submitted to binding arbitration under the Maryland Uniform Arbitration Act, with venue in [COUNTY], Maryland.
☐ Arbitration Declined – Disputes shall proceed in state court as provided in Section 8.3.

8.3 Forum Selection
If arbitration is not elected, exclusive jurisdiction and venue shall lie in the state courts located in [COUNTY], Maryland.

8.4 Jury Trial
Nothing herein shall constitute a waiver of any party’s constitutional right to trial by jury.

8.5 Injunctive Relief
The parties acknowledge that monetary damages may not adequately remedy unauthorized disclosure of PHI or intellectual property. A party may seek limited injunctive relief to prevent such disclosure, subject to Maryland equitable principles.

IX. GENERAL PROVISIONS

9.1 Amendments & Waivers
No amendment or waiver is effective unless in a signed writing that refers expressly to this Agreement. A waiver on one occasion is not a waiver on any subsequent occasion.

9.2 Assignment
Neither party may assign or delegate its rights or obligations without the prior written consent of the other, except that Provider may assign to an affiliated entity or successor in interest upon thirty (30) days’ notice.

9.3 Successors & Assigns
This Agreement binds and benefits the parties and their respective successors and permitted assigns.

9.4 Severability
If any provision is held unenforceable, the remainder shall be enforced, and the unenforceable provision reformed to the minimum extent necessary to effectuate the parties’ intent.

9.5 Integration
This Agreement, together with all exhibits and attachments, constitutes the entire understanding regarding the subject matter and supersedes all prior oral or written agreements.

9.6 Counterparts; Electronic Signatures
This Agreement may be executed in counterparts, each of which is deemed an original. Electronic or facsimile signatures shall be deemed originals for all purposes.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the parties execute this Agreement on the dates indicated below.

PROVIDER:
________________________________________
Authorized Signatory
Name: [PRINT]
Title: [PRINT]
Date: ____________________

PATIENT:
☐ Patient has Capacity and signs personally
☐ Patient lacks Capacity; Authorized Representative signs below

________________________________________
Signature
Name: [PRINT]
Relationship (if not Patient): ____________________
Legal Authority (attach documentation): ___________
Date: ____________________

WITNESS: (required if Patient signs with mark or as otherwise required by Provider policy)
________________________________________
Name & Signature
Date: ____________________

[OPTIONAL NOTARY BLOCK – complete only if notarization is required by institutional policy or elected by parties.]

EXHIBIT A

Treatment Plan, Risks, Benefits, and Alternatives