Patient Consent Form - Treatment (New Hampshire)

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. New Hampshire and federal requirements governing informed consent and medical malpractice are complex and subject to change; a qualified New Hampshire-licensed attorney and the treating clinician must review, customize, and approve this form before implementation.

PATIENT CONSENT TO TREATMENT AGREEMENT

(New Hampshire - Comprehensive Informed Consent Form)

I. PURPOSE AND ACKNOWLEDGMENT

A. Purpose. This Agreement records the informed consent of Patient (or Representative) to one or more medical treatments, procedures, or services (collectively, "Treatment") to be furnished by Provider, in compliance with N.H. RSA 507-E:2 and applicable New Hampshire common law governing physician disclosure obligations (see Smith v. Cote, 128 N.H. 231 (1986)).

B. Consideration. In consideration of Provider's agreement to furnish Treatment, the Parties agree as set forth herein.

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, evaluated consistent with N.H. RSA ch. 137-J.

"Confidential Information" - Individually identifiable health information protected by HIPAA (45 C.F.R. Parts 160 and 164) and applicable New Hampshire confidentiality law.

"Emergency Condition" - A condition in which delay in Treatment would jeopardize Patient's life, health, or bodily function.

"Informed Consent" - Voluntary authorization given by Patient (or Representative) after disclosure of: (i) the diagnosis; (ii) the nature of the proposed Treatment; (iii) material risks and expected benefits; (iv) reasonable alternatives, including the option of no treatment; and (v) responses to Patient's questions, in a manner satisfying N.H. RSA 507-E:2, II.

"Material Issues" - The factors enumerated in N.H. RSA 507-E:2, II(b): (1) whether the person giving consent could reasonably be expected to know of the risks; (2) whether such person actually knew of the risks; (3) whether the injured party would have undergone the Treatment regardless of the risk or declined to be informed; and (4) whether it was reasonable to limit disclosure because disclosure could adversely and substantially affect the Patient's condition.

"PHI" - Protected Health Information as defined in 45 C.F.R. § 160.103.

III. OPERATIVE PROVISIONS

3.1 Description of Treatment.

• a. Nature of Treatment: [DETAILED DESCRIPTION].
• b. Expected Benefits: [DESCRIPTION].
• c. Material Risks & Complications: [LIST OR attach Schedule 1].
• d. Reasonable Alternatives (including no treatment): [LIST].
• e. Consequences of Declining or Delaying Treatment: [LIST].

3.2 Disclosure Standard. Provider has disclosed, and Patient acknowledges receipt of, information sufficient to satisfy New Hampshire's professional disclosure standard under N.H. RSA 507-E:2 and the duty to disclose material risks recognized in Smith v. Cote, 128 N.H. 231 (1986).

3.3 Voluntary Consent. Patient confirms that consent is given voluntarily and may be withdrawn in writing at any time prior to the performance of Treatment, subject to medical necessity and Section VI.

3.4 Right to Ask Questions. Patient was encouraged to ask questions, and all questions were answered to Patient's satisfaction.

3.5 Financial Responsibility. Patient agrees to be financially responsible for charges associated with Treatment that are not covered by insurance. [PLACEHOLDER - insert billing policy].

3.6 Confidentiality & Privacy. Provider will use Confidential Information solely for Treatment, payment, and health-care operations, consistent with HIPAA. Patient consents to such use and acknowledges receipt of Provider's Notice of Privacy Practices.

3.7 Capacity Verification. Provider has verified Patient's Capacity. If Patient lacks Capacity, Provider has obtained consent from a Representative authorized under N.H. RSA ch. 137-J (Durable Power of Attorney for Health Care, Living Will, or default surrogate).

3.8 Emergency Treatment Exception. In an Emergency Condition where informed consent cannot practicably be obtained, Provider may proceed pursuant to N.H. RSA 507-E:2 and the common-law emergency exception.

3.9 Minor Consent (Limited Exceptions). Patient acknowledges that under New Hampshire law:

• ☐ The age of majority is eighteen (18) (N.H. RSA 21:30); a parent or legal guardian must generally consent for minors.
• ☐ A minor fourteen (14) or older may consent to STD diagnosis and treatment without parental consent (N.H. RSA 141-C:18).
• ☐ A minor twelve (12) or older may consent to drug-abuse treatment without parental consent (N.H. RSA 318-B:12-a).
• ☐ Emancipated minor (attach documentation).

IV. REPRESENTATIONS & WARRANTIES

4.1 Patient/Representative Representations.

• a. Authority. Representative warrants legal authority to act for Patient under N.H. RSA ch. 137-J or otherwise.
• b. Accuracy. All information furnished is true, complete, and accurate.
• c. Understanding. Patient/Representative represents understanding of this Agreement.

4.2 Provider Representations.

• a. Licensure. Provider and Treating Clinician are duly licensed in New Hampshire pursuant to N.H. RSA ch. 329 or other applicable licensing chapter.
• b. Standard of Care. Treatment will be rendered consistent with the prevailing professional standard of care for the relevant specialty in New Hampshire.
• c. Disclosure Compliance. Provider has made disclosures sufficient to satisfy N.H. RSA 507-E:2.

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 N.H. Board of Medicine rules (Med 502) and HIPAA.
• b. Insurance. Provider shall maintain professional liability insurance in commercially reasonable amounts.

VI. DEFAULT & REMEDIES

6.1 Events of Default. (a) Non-payment by Patient; (b) material misrepresentation by any Party; (c) withdrawal of consent during an ongoing procedure (except as permitted at law).

6.2 Notice & Cure. Ten (10) calendar days to cure a monetary default; up to fifteen (15) calendar days to cure a non-monetary default.

6.3 Remedies. Suspension or termination of non-emergency Treatment; recovery of reasonable collection costs; any other remedy available at law or equity.

VII. RISK ALLOCATION

7.1 No Limitation of Malpractice Liability. Nothing in this Agreement waives or limits Patient's rights under N.H. RSA ch. 507-E or any other applicable law. New Hampshire does not impose a statutory cap on non-economic medical-malpractice damages.

7.2 Indemnification (Limited). Patient agrees to indemnify Provider only for liability arising from Patient's breach of this Agreement or failure to follow medical instructions, and not for any claim arising out of Provider's negligence or willful misconduct.

7.3 Force Majeure. Provider shall not be liable for delay or failure to perform due to events beyond its reasonable control.

VIII. DISPUTE RESOLUTION

8.1 Governing Law. This Agreement is governed by New Hampshire law, without regard to conflict-of-laws principles.

8.2 Forum. Exclusive venue shall lie in the New Hampshire Superior Court for the county in which Treatment is rendered.

8.3 Optional Pre-Suit Screening. Patient acknowledges that medical-injury actions in New Hampshire may be subject to pre-suit screening under N.H. RSA ch. 519-B.

8.4 Jury Trial Preserved. The Parties acknowledge the constitutional right to a jury trial and do not waive that right by signing this Agreement.

IX. GENERAL PROVISIONS

9.1 Amendments. Any amendment must be in a signed writing referencing this Agreement.
9.2 Assignment. Patient may not assign rights without Provider's prior written consent.
9.3 Severability. If any provision is held invalid, the remainder remains enforceable.
9.4 Integration. This Agreement, together with attachments and Provider's Notice of Privacy Practices, constitutes the entire agreement.
9.5 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts and via electronic signature.

X. EXECUTION

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

A. Patient / Representative

B. Provider

C. Witness (if required by facility policy)

SCHEDULE 1 - DISCLOSURE OF MATERIAL RISKS & ALTERNATIVES

[Use plain language understandable to Patient. Tailor to each specific procedure. Address the four "material issues" under N.H. RSA 507-E:2, II(b).]

SCHEDULE 2 - NOTICE OF PRIVACY PRACTICES

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

SOURCES AND REFERENCES

• N.H. RSA 507-E:2 - Burden of Proof; Informed Consent
• N.H. RSA ch. 137-J - Written Directives for Medical Decision Making
• N.H. RSA 21:30 - Age of Majority
• N.H. RSA 141-C:18 - Sexually Transmitted Disease (Minor Consent)
• N.H. RSA 318-B:12-a - Treatment for Drug Abuse (Minor Consent)
• Smith v. Cote, 128 N.H. 231 (1986)
• HIPAA, 45 C.F.R. Parts 160 & 164