Patient Consent Form - Treatment (Missouri)

DISCLAIMER (MANDATORY — DO NOT DELETE)
This document is a model template for educational purposes only and does not constitute legal or medical advice. Use of this template does not create an attorney-client or physician-patient relationship. Missouri informed-consent doctrine, capacity law, and federal HIPAA requirements are complex; a Missouri-licensed attorney and the treating clinician must review, customize, and approve this form before implementation.

PATIENT CONSENT TO TREATMENT

State of Missouri — Comprehensive Informed Consent Form

I. PURPOSE AND ACKNOWLEDGMENT

A. Purpose. This Agreement records the informed consent of Patient (or Representative) for the performance of one or more medical treatments, procedures, or services (collectively, "Treatment") by Provider in compliance with Missouri informed-consent standards established under Aiken v. Clary, 396 S.W.2d 668 (Mo. 1965), and progeny, and consistent with RSMo § 431.061.

B. Consideration. In consideration of Provider's agreement to furnish Treatment and related services, and other good and valuable consideration, the Parties agree as set forth herein.

C. Acknowledgment of Receipt. Patient acknowledges receipt of a copy of this Agreement and that the provisions have been explained in language Patient understands.

II. DEFINITIONS

• "Adverse Event" — Any unanticipated injury or complication arising in connection with Treatment that may require further medical intervention.
• "Capacity" — The ability to understand the nature, risks, benefits, and alternatives of Treatment and to make and communicate a decision, consistent with Missouri common law and RSMo §§ 475.075, 404.825.
• "Confidential Information" — Individually identifiable health information protected by HIPAA (45 C.F.R. Parts 160, 164) and applicable Missouri privacy law.
• "Emergency Condition" — A condition in which delay in Treatment would jeopardize Patient's life, health, or bodily function, in which event consent may be implied under Missouri common law and RSMo § 431.061.
• "Treatment" — Any medical, surgical, diagnostic, anesthetic, immunization, pharmacologic, or therapeutic procedure performed or ordered by Provider.

III. AUTHORITY TO CONSENT (RSMo § 431.061)

The following persons are authorized to consent to Treatment under RSMo § 431.061:

☐ Any adult eighteen (18) years of age or older, for himself or herself.
☐ A parent or legal custodian, for a minor child in legal custody.
☐ A lawfully married minor, or a minor parent or legal custodian, for himself/herself or such child.
☐ An adult standing in loco parentis in the case of an emergency.
☐ A guardian or conservator appointed under RSMo Chapter 475.
☐ An attorney-in-fact under a Durable Power of Attorney for Health Care (RSMo §§ 404.800–404.872).
☐ A relative caregiver pursuant to a valid affidavit under RSMo § 431.058.

Minor Self-Consent (RSMo § 431.061.4). A minor may consent to Treatment for the following without parental involvement:

☐ Pregnancy (excluding abortion, which is governed by separate statutes).
☐ Venereal/sexually transmitted disease (any minor; minors twelve (12) years of age or older may consent to STD examination and treatment).
☐ Drug or substance abuse.

☐ Patient is an emancipated minor under RSMo § 431.056 and consents in his/her own right.

IV. NATURE OF THE PROPOSED TREATMENT

V. DISCLOSURE OF MATERIAL RISKS

Under Aiken v. Clary, 396 S.W.2d 668 (Mo. 1965), and its progeny, a Missouri physician must disclose information that a reasonable medical practitioner would disclose under the same or similar circumstances. Patient acknowledges disclosure of, and understanding of, the following material risks specific to the proposed Treatment:

☐ Bleeding, hemorrhage, or hematoma
☐ Infection (local or systemic)
☐ Adverse reaction to medication or anesthesia
☐ Damage to surrounding nerves, organs, or tissues
☐ Need for additional or different procedures
☐ Loss of function, paralysis, or disfigurement
☐ Death (in rare circumstances)
☐ Procedure-specific risks: [_________________________________]
☐ Off-label or experimental aspects (if applicable): [_________________________________]

VI. CAPACITY ATTESTATION

Provider has assessed Patient's capacity to consent. Patient (or Representative):

☐ Demonstrates capacity to understand the nature, purpose, risks, benefits, and alternatives of Treatment.
☐ Lacks capacity; consent is provided by an authorized surrogate identified in Section III.
☐ Has executed an Advance Directive under RSMo Chapter 459 — copy on file: ☐ Yes ☐ No
☐ Has executed a Durable Power of Attorney for Health Care under RSMo §§ 404.800–404.872 — copy on file: ☐ Yes ☐ No

VII. RIGHT TO ASK QUESTIONS AND TO REFUSE OR WITHDRAW CONSENT

Patient has had the opportunity to ask questions, all of which have been answered to Patient's satisfaction. Patient understands that consent may be refused or withdrawn at any time prior to Treatment, except where withdrawal would create an immediate medical emergency.

VIII. RELEASE OF TISSUE / SPECIMENS / IMAGES

☐ Patient consents to disposal of tissue, fluids, and specimens removed during Treatment in accordance with Provider's standard practices and applicable law.
☐ Patient consents to photography or video recording solely for documentation, education, or quality-assurance purposes, with identifying information removed where feasible.

IX. FINANCIAL DISCLOSURE AND ASSIGNMENT OF BENEFITS

☐ Patient acknowledges that not all costs may be covered by insurance.
☐ Patient assigns insurance benefits payable for Treatment directly to Provider.
☐ Patient agrees to pay any unpaid balance after insurance adjudication.

X. PRIVACY (HIPAA / MISSOURI)

Patient acknowledges receipt of Provider's Notice of Privacy Practices issued pursuant to 45 C.F.R. § 164.520. Provider will use and disclose Confidential Information consistent with HIPAA, RSMo § 191.227 (patient access to records), and other applicable Missouri law.

XI. EMERGENCY EXCEPTION

In the event of an Emergency Condition arising during or after Treatment, Provider may render additional services reasonably necessary to preserve Patient's life or health, consistent with Missouri common-law implied consent and RSMo § 431.061.

XII. DISPUTE RESOLUTION

Any dispute arising under or relating to this Agreement shall be governed by Missouri law. Venue shall lie in the circuit court of the Missouri county in which Treatment was rendered, except as may be otherwise required by binding contract or statute.

XIII. EXECUTION

By signing below, the undersigned acknowledge that they have read this Agreement (or had it read to them), understand it, and consent to Treatment as described.

SOURCES AND REFERENCES

• RSMo § 431.061 — Consent to surgical or medical treatment, who may give, when.
• RSMo § 431.056 — Emancipated minor consent.
• RSMo Chapter 459 — Missouri Life Support Declarations Act (Living Wills).
• RSMo §§ 404.800–404.872 — Durable Power of Attorney for Health Care.
• Aiken v. Clary, 396 S.W.2d 668 (Mo. 1965).
• Wilkerson v. Mid-America Cardiology, 908 S.W.2d 691 (Mo. App. W.D. 1995).
• 45 C.F.R. Parts 160, 164 — HIPAA Privacy & Security Rules.