PATIENT CONSENT TO TREATMENT FORM
(New Jersey – Comprehensive Template)
[// GUIDANCE: This template is designed for inpatient or outpatient medical and surgical procedures performed in the State of New Jersey. Bracketed items must be customized for each engagement. Remove all guidance comments prior to execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Consent to Treatment
3.2 Provider Disclosures
3.3 Patient Acknowledgments & Representations
3.4 Capacity & Surrogate Decision-Making
3.5 Withdrawal or Refusal of Consent
3.6 Payment & Financial Responsibility - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
7.1 Indemnification (Informed-Consent Protection)
7.2 Limitation of Liability / Malpractice Limits - Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
Patient: [PATIENT LEGAL NAME], DOB [MM/DD/YYYY]
Authorized Representative (if any): [NAME & CAPACITY]
Treating Physician/Provider: [BOARD-CERTIFIED SPECIALTY & NAME]
Facility: [HOSPITAL/CLINIC NAME & ADDRESS]
Designated Procedure/Treatment: [DESCRIBE WITH CPT/HCPCS CODE IF APPLICABLE]
Effective Date: [DATE OF SIGNATURE OR EARLIER OF TREATMENT]
Governing Law: State of New Jersey medical law and applicable federal regulations
Recitals
A. Patient seeks to receive the Designated Procedure from Provider at Facility.
B. Provider has furnished to Patient all material information required under New Jersey informed-consent standards, including nature, purpose, risks, benefits, and alternatives.
C. Patient (or Authorized Representative) desires to provide informed consent upon the terms set forth herein.
2. DEFINITIONS
For purposes of this Consent Form, capitalized terms have the meanings set forth below. Undefined capitalized terms shall be interpreted in accordance with customary medical-legal usage in New Jersey.
“Ancillary Services” – Any diagnostic, therapeutic, or palliative services reasonably related to or arising during the Designated Procedure, including laboratory work, imaging, anesthesia, postoperative care, and emergency intervention.
“Authorized Representative” – An individual legally empowered to act on Patient’s behalf with respect to health-care decisions, including but not limited to a parent of a minor, a court-appointed guardian, or a valid health-care proxy.
“Informed Consent” – The voluntary authorization by Patient (or Authorized Representative) to proceed with the Designated Procedure after having received, comprehended, and considered Provider Disclosures consistent with New Jersey law and prevailing professional standards.
“Protected Health Information” or “PHI” – Individually identifiable health information protected under HIPAA, 45 C.F.R. Parts 160 & 164.
“Provider” – Collectively, the Treating Physician, Facility, any consulting specialists, residents, nurses, technicians, certified registered nurse anesthetists (“CRNAs”), and other individuals or entities participating in the Designated Procedure or Ancillary Services.
3. OPERATIVE PROVISIONS
3.1 Consent to Treatment
(a) By signing below, Patient hereby:
(i) Grants Provider permission to perform the Designated Procedure and all Ancillary Services deemed medically necessary, including the administration of anesthesia and blood products;
(ii) Authorizes Provider to record and retain clinical photographs, audio, or video images for medical documentation, treatment, and operational quality assessment, subject to HIPAA; and
(iii) Acknowledges that no specific result or cure has been guaranteed.
(b) Initial Here to Confirm Consent: ______
3.2 Provider Disclosures
Provider confirms that, prior to obtaining signature, Patient received information sufficient to satisfy New Jersey’s informed-consent requirements, including:
1. Diagnosis and nature of Patient’s condition;
2. Description, anticipated benefits, and likelihood of success of the Designated Procedure;
3. Material risks and specific foreseeable complications (common and significant);
4. Reasonable alternative treatments (including no treatment) and respective risks/benefits;
5. Expected recovery process, post-procedure limitations, and follow-up requirements;
6. Identification of who will perform material parts of the Procedure, including residents/fellows;
7. Availability of interpreters and translated materials where indicated.
3.3 Patient Acknowledgments & Representations
Patient represents that:
(a) All questions have been answered to Patient’s satisfaction;
(b) Patient has been offered written materials summarizing the disclosure items above;
(c) No medication or condition is presently impairing Patient’s ability to understand; and
(d) Patient’s decision is voluntary and free from coercion.
3.4 Capacity & Surrogate Decision-Making
(a) Patient affirms legal capacity (18 years or older and of sound mind) OR has supplied evidence of Authorized Representative status.
(b) If Patient loses capacity prior to completion of the Designated Procedure, Patient authorizes Provider to rely on (i) any existing advance directive, or (ii) the next appropriate surrogate under N.J. statutes.
3.5 Withdrawal or Refusal of Consent
Patient may revoke this Consent, orally or in writing, at any time prior to commencement of the Designated Procedure, except to the extent Provider has already relied upon it. Revocation shall not relieve Patient of responsibility for reasonable charges incurred to that point.
3.6 Payment & Financial Responsibility
(a) Patient (or guarantor) remains responsible for all charges not covered by insurance, including co-payments, deductibles, or denied claims.
(b) Assignment of benefits: Patient assigns to Provider any insurance proceeds payable for services rendered.
(c) Default Interest & Collection Costs: Overdue balances bear interest at [X]% per annum, subject to New Jersey usury limits. Patient is liable for reasonable attorney fees and collection costs upon default.
4. REPRESENTATIONS & WARRANTIES
4.1 Provider represents that the Treating Physician:
(a) Holds a current, unrestricted license in the State of New Jersey; and
(b) Will exercise the degree of skill and care ordinarily possessed by prudent practitioners in the same specialty under similar circumstances.
4.2 Survival. Provider’s representations in § 4.1 survive completion of services to the extent required by law.
5. COVENANTS & RESTRICTIONS
5.1 Patient covenants to:
(a) Provide accurate medical history and medication information;
(b) Comply with postoperative instructions; and
(c) Promptly report unexpected symptoms or complications.
5.2 Provider covenants to maintain the confidentiality of PHI in accordance with HIPAA and New Jersey privacy statutes.
6. DEFAULT & REMEDIES
6.1 Patient Default. Failure to make timely payment constitutes default. Provider may pursue all lawful collection remedies after providing written notice and a 15-day cure period.
6.2 Provider Default. Alleged breach of Provider’s obligations shall be addressed through the dispute-resolution procedures in Article 8. This section does not impair statutory malpractice rights.
7. RISK ALLOCATION
7.1 Indemnification (Informed-Consent Protection)
Patient agrees to indemnify and hold harmless Provider against claims, damages, or liabilities arising solely from (i) Patient’s material misstatements or omissions regarding medical history, or (ii) unauthorized use or disclosure by Patient of Provider-supplied educational materials. This indemnity shall not extend to malpractice, negligence, or violations of New Jersey consumer-protection law.
7.2 Limitation of Liability / Malpractice Limits
Nothing in this Consent Form waives or limits Patient’s non-waivable rights under New Jersey medical-malpractice statutes or caps Provider’s liability beyond any statutory limitations on damages, if applicable. Any contractual limitation inconsistent with governing law shall be deemed modified to the minimum extent necessary for enforceability.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Consent Form and any dispute arising hereunder shall be governed by the substantive laws of the State of New Jersey, without regard to conflict-of-laws principles.
8.2 Forum Selection. Exclusive venue shall lie in the state courts located in [COUNTY], New Jersey, unless the parties mutually elect arbitration per § 8.3.
8.3 Optional Arbitration. By initialing below, both parties may irrevocably agree to submit all claims (excluding requests for emergent injunctive relief) to binding arbitration in accordance with the New Jersey Uniform Arbitration Act and the prevailing rules of [ARBITRATION ORGANIZATION].
• Patient Initials (Arbitration Opt-In): __
• Provider Initials (Arbitration Opt-In): ____
8.4 Jury Waiver. TO THE EXTENT PERMITTED BY THE NEW JERSEY CONSTITUTION, THE PARTIES KNOWINGLY AND VOLUNTARILY WAIVE TRIAL BY JURY IN ANY ACTION NOT SUBJECT TO ARBITRATION.
8.5 Injunctive Relief. Either party may seek temporary or preliminary injunctive relief from the designated state court to preserve the status quo pending resolution on the merits, subject to equitable limitations.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers. Any amendment must be in writing, signed by both parties. No waiver of any provision shall be deemed a continuing waiver unless expressly stated.
9.2 Assignment. Patient may not assign rights or delegate duties under this Consent Form without Provider’s prior written consent. Provider may assign billing rights.
9.3 Successors & Assigns. This Consent Form binds and benefits the parties and their lawful successors and permitted assigns.
9.4 Severability. Any invalid or unenforceable provision shall be reformed to the minimum extent necessary; the remainder shall continue in effect.
9.5 Integration. This Consent Form, together with HIPAA Notice of Privacy Practices and any Advance Directive on file, constitutes the entire agreement regarding the subject matter and supersedes all prior oral or written statements.
9.6 Counterparts & Electronic Signatures. The parties may execute this Consent Form in multiple counterparts (including electronic or facsimile copies), each of which shall be deemed an original. Electronic signatures are binding under N.J. Stat. Ann. Title 12A (Uniform Electronic Transactions Act).
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the undersigned have executed this Patient Consent to Treatment Form as of the Effective Date.
PATIENT
Signature: ____
Printed Name: ____
Date: ________
AUTHORIZED REPRESENTATIVE (if applicable)
Capacity/Relationship: ____
Signature: _____
Printed Name: ____
Date: _____
PROVIDER
Treating Physician Signature: _____
Printed Name: _____
N.J. License No.: ____
Date: __________
WITNESS (optional unless facility policy or Patient’s inability to sign mandates)
Witness Signature: ____
Printed Name: ____
Date: ________
[// GUIDANCE: Facilities that require notarization or interpreter certification should insert appropriate blocks here.]
END OF DOCUMENT