Patient Consent Form - Treatment (Nebraska)

PATIENT CONSENT TO TREATMENT AGREEMENT

(Nebraska – 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 Neb. Rev. Stat. § 44-2816 and other applicable Nebraska law.

B. Standard of Disclosure. Under § 44-2816, "informed consent" means consent to a procedure based on information that would ordinarily be provided to the patient under like circumstances by health care providers engaged in a similar practice in the locality or in similar localities. Nebraska has adopted the professional/locality theory of physician disclosure; expert testimony is generally required to establish the applicable standard.

C. Acknowledgment of Receipt. Patient acknowledges receipt of a copy of this Agreement and that its 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, as determined consistent with applicable Nebraska law and clinical judgment.

"Confidential Information" – Individually identifiable health information protected under HIPAA (45 C.F.R. Parts 160, 164) and applicable Nebraska law.

"Emergency Condition" – A condition in which delay in Treatment would jeopardize Patient's life, health, or bodily function such that informed consent cannot practicably be obtained.

"Health Care Power of Attorney" – A power of attorney for health care decisions executed pursuant to Neb. Rev. Stat. § 30-3401 et seq.

"Informed Consent" – Voluntary authorization given by Patient or Representative after disclosure of: (i) diagnosis; (ii) proposed Treatment; (iii) material risks and expected benefits; (iv) reasonable alternatives (including the option of no treatment); and (v) answers to Patient's questions, in a manner consistent with Nebraska's locality/professional standard under § 44-2816.

"Minor" – A person under nineteen (19) years of age, per Neb. Rev. Stat. § 43-2101. (Nebraska's age of majority is 19, not 18.) Minority ends upon valid marriage.

"Protected Health Information (PHI)" – As defined in 45 C.F.R. § 160.103.

III. OPERATIVE PROVISIONS

3.1 Description of Treatment

3.2 Disclosure Compliance

Provider has disclosed information sufficient to satisfy Nebraska's professional disclosure standard under § 44-2816 and has answered Patient's questions to Patient's stated satisfaction.

3.3 Voluntary Consent

Patient confirms that consent is given voluntarily and may be withdrawn at any time prior to performance of Treatment, except where withdrawal would create a substantial risk of harm during an ongoing procedure.

3.4 Capacity Verification

Provider has verified Patient's Capacity. If Patient lacks Capacity, Provider has obtained consent from a Representative authorized under one of the following:

☐ Health Care Power of Attorney pursuant to Neb. Rev. Stat. § 30-3401 et seq.
☐ Court-appointed guardian with health care authority.
☐ Surrogate decision-maker permitted by Nebraska law and facility policy.
☐ Advance directive under the Rights of the Terminally Ill Act, Neb. Rev. Stat. § 20-401 et seq.

3.5 Minor Patient Consent (Nebraska)

Where Patient is a Minor (under age 19 per § 43-2101), consent is obtained from a parent or legal guardian unless an exception applies:

☐ Emancipated minor (verify documentation).
☐ Married minor (minority ends upon valid marriage per § 43-2101).
☐ Minor consenting to examination or treatment for sexually transmitted disease per Neb. Rev. Stat. § 71-504.
☐ Minor consenting to substance abuse treatment per Neb. Rev. Stat. § 83-1,148.
☐ Emergency Condition under Section 3.7.
☐ Other statutory exception: [CITE].

3.6 Right to Ask Questions

Patient was encouraged to ask questions. All questions were answered to Patient's satisfaction prior to signing this Agreement.

3.7 Emergency Treatment Exception

In an Emergency Condition where informed consent cannot practicably be obtained, Provider may proceed under the implied-consent doctrine and applicable Nebraska law.

3.8 Financial Responsibility

Patient agrees to be financially responsible for charges associated with Treatment not covered by insurance. [INSERT BILLING POLICY OR REFERENCE.]

3.9 Confidentiality and Privacy

Provider will use Confidential Information for Treatment, payment, and health care operations consistent with HIPAA and applicable Nebraska law. Patient acknowledges receipt of Provider's Notice of Privacy Practices.

IV. REPRESENTATIONS AND WARRANTIES

4.1 Patient/Representative

(a) Authority and Identity. Representative warrants legal authority to act for Patient (e.g., POA, guardianship, parental authority for a Minor under § 43-2101).
(b) Accuracy of Information. All information furnished is true, complete, and accurate to the best of Patient's knowledge.
(c) Understanding. Patient/Representative represents understanding of this Agreement, including the disclosed risks, benefits, and alternatives.

4.2 Provider

(a) Licensure and Qualifications. Provider and Treating Clinician are duly licensed under the Nebraska Uniform Credentialing Act, Neb. Rev. Stat. § 38-101 et seq., and the Medical Practice Act, § 38-2001 et seq.
(b) Standard of Care. Treatment will be rendered consistent with prevailing professional standards in the locality or similar localities under § 44-2816.
(c) Disclosure Compliance. Provider has made disclosures sufficient for Informed Consent under Nebraska law.

V. COVENANTS

5.1 Patient Covenants

(a) Cooperation. Patient shall cooperate with pre- and post-Treatment instructions.
(b) Notification. Patient must promptly notify Provider of any Adverse Event or material change in condition.

5.2 Provider Covenants

(a) Recordkeeping. Provider shall maintain medical records consistent with HIPAA and Nebraska Department of Health and Human Services regulations.
(b) Insurance. Provider shall maintain professional liability insurance in compliance with the Nebraska Hospital-Medical Liability Act, Neb. Rev. Stat. § 44-2801 et seq., where applicable.

VI. RISK ALLOCATION

6.1 Indemnification. Patient agrees to indemnify and hold harmless Provider for claims arising out of Patient's breach of this Agreement or failure to follow medical instructions, except to the extent caused by Provider's negligence or willful misconduct.

6.2 Limitation of Liability. Nothing herein limits Provider's liability for professional negligence beyond limits permitted by Nebraska law (including the Hospital-Medical Liability Act, where applicable).

6.3 No Guarantee of Outcome. Patient understands that medicine is not an exact science and that Provider has not guaranteed any particular outcome.

VII. DISPUTE RESOLUTION

7.1 Governing Law. This Agreement is governed by the laws of the State of Nebraska, without regard to conflict-of-laws principles.

7.2 Forum. Exclusive venue shall lie in the Nebraska state district court for the county in which Treatment is rendered, except where preempted by federal law.

7.3 Hospital-Medical Liability Act. If Provider is a "qualified" health care provider under Neb. Rev. Stat. § 44-2801 et seq., claims may proceed through the medical review panel and other procedures of that Act.

7.4 Jury Trial. The Parties acknowledge the constitutional right to a jury trial in civil actions and do not waive that right by signing this Agreement.

VIII. GENERAL PROVISIONS

8.1 Amendments. Any amendment must be in a signed writing referencing this Agreement.

8.2 Severability. If any provision is held invalid, the remaining provisions shall remain enforceable, and the invalid provision shall be reformed to the minimum extent necessary to comply with applicable law.

8.3 Integration. This Agreement, together with any schedules and Provider's Notice of Privacy Practices, constitutes the entire agreement regarding the subject matter.

8.4 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts, including electronic signatures, each of which is deemed an original.

IX. EXECUTION

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.

A. Patient or Authorized Representative

B. Provider / Treating Clinician

C. Witness (if required by facility policy)

SCHEDULE 1 – DISCLOSURE OF MATERIAL RISKS AND ALTERNATIVES

[Use plain language and medical terminology understandable to Patient. Tailor to each specific procedure and document the locality-relevant disclosures expected of similarly situated Nebraska practitioners under § 44-2816.]

SCHEDULE 2 – NOTICE OF PRIVACY PRACTICES

[Attach most recent HIPAA-compliant notice or incorporate by reference.]

SCHEDULE 3 – ADVANCE DIRECTIVE / POA STATUS

☐ Health Care POA on file (Neb. Rev. Stat. § 30-3401 et seq.)
☐ Living Will / Declaration under Rights of the Terminally Ill Act (§ 20-401 et seq.)
☐ POLST or similar physician order on file
☐ None on file – patient declined to execute at this time

SOURCES AND REFERENCES

• Neb. Rev. Stat. § 44-2816 (informed consent — locality/professional standard)
• Neb. Rev. Stat. § 44-2801 et seq. (Hospital-Medical Liability Act)
• Neb. Rev. Stat. § 30-3401 et seq. (Health Care Power of Attorney Act)
• Neb. Rev. Stat. § 20-401 et seq. (Rights of the Terminally Ill Act)
• Neb. Rev. Stat. § 43-2101 (age of majority — 19 in Nebraska)
• Neb. Rev. Stat. § 71-504 (minor consent — STD treatment)
• Neb. Rev. Stat. § 83-1,148 (minor consent — substance abuse treatment)
• Neb. Rev. Stat. § 38-2001 et seq. (Medical Practice Act, within Uniform Credentialing Act)
• 45 C.F.R. Parts 160, 164 (HIPAA)