PATIENT CONSENT TO MEDICAL TREATMENT
(New York – Comprehensive Form)
[// GUIDANCE: This template is drafted for use by New York–licensed hospitals, ambulatory surgery centers, physician practices, and other health-care providers. Customize all bracketed items, confirm alignment with institutional policies, and obtain clinical input for procedure-specific disclosures.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Consent to Treatment
3.2 Disclosure of Material Information
3.3 Voluntary Consent & Withdrawal Rights
3.4 Financial Responsibility
3.5 Conditions Precedent & Subsequent - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
7.1 Indemnification
7.2 Limitation of Liability
7.3 Force Majeure / Emergency Deviation - Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title. Patient Consent to Medical Treatment (the “Agreement”).
1.2 Parties.
(a) “[PROVIDER LEGAL NAME],” a health-care provider duly licensed under the laws of the State of New York (“Provider”); and
(b) “[PATIENT FULL LEGAL NAME]” or the Patient’s Authorized Representative, as applicable (“Patient”).
1.3 Recitals.
A. Provider proposes to furnish certain medical, surgical, diagnostic, therapeutic, or other health-care services to Patient (collectively, the “Treatment”).
B. Patient desires to receive such Treatment based on informed consent, consistent with N.Y. Pub. Health Law § 2805-d and other applicable law.
C. The parties therefore enter into this Agreement as of the Effective Date defined below.
1.4 Effective Date. “[DATE]”.
1.5 Governing Law / Jurisdiction. This Agreement and all disputes arising hereunder shall be governed by the laws of the State of New York without regard to its conflict-of-laws principles (“Governing Law”). See Section 8 for forum and dispute resolution provisions.
2. DEFINITIONS
For purposes of this Agreement, capitalized terms have the meanings set forth below. Defined terms appear alphabetically for ease of reference.
2.1 “Authorized Representative” – An individual legally authorized to make health-care decisions on behalf of the Patient, including but not limited to a health-care proxy, parent of a minor, or court-appointed guardian.
2.2 “Capacity” – A Patient’s ability, as determined by Provider in accordance with clinical judgment and applicable law, to understand relevant information, appreciate foreseeable consequences, and make an informed, voluntary decision. [// GUIDANCE: Capacity determinations should conform to N.Y. Mental Hygiene Law § 81.29 and related standards.]
2.3 “Informed Consent” – A decision by Patient (or Authorized Representative) to accept the proposed Treatment after receiving and understanding adequate information regarding the procedure, alternatives, risks, benefits, and consequences of non-treatment.
2.4 “Material Risk” – Any risk that a reasonable person in the Patient’s position would deem significant when deciding whether to undergo the Treatment.
2.5 “Minor” – An individual under eighteen (18) years of age who has not otherwise attained the legal capacity to consent pursuant to N.Y. Pub. Health Law §§ 2504, 2781, or other applicable provisions.
2.6 “Treatment” – The specific medical, surgical, diagnostic, therapeutic, or other health-care services described in Section 3.1, including all related anesthesia, pathology, laboratory, radiological, pharmaceutical, nursing, telemedicine, and ancillary services.
3. OPERATIVE PROVISIONS
3.1 Consent to Treatment
(a) Description. Patient hereby consents to the following Treatment:
• Procedure/Service: “[DESCRIBE IN LAY TERMS – e.g., ‘Laparoscopic Cholecystectomy’]”
• Treating Clinician(s): “[NAME & CREDENTIALS]”
• Location: “[FACILITY NAME & ADDRESS]”
(b) Ancillary Services. Patient further consents to such ancillary, diagnostic, or therapeutic services, including anesthesia and blood transfusion, as Provider deems reasonably necessary in the course of Treatment.
3.2 Disclosure of Material Information
Provider has disclosed, and Patient acknowledges receipt and understanding of, the following information:
1. Diagnosis/Indication for Treatment.
2. Purpose and expected outcome.
3. Material Risks (including quantitative data where available).
4. Likely benefits.
5. Reasonable alternatives, including the option of no treatment and associated risks.
6. Name(s) of all physicians with significant roles.
7. Estimated recovery period and post-treatment requirements.
8. Capacity determination, interpreter services provided, and opportunity to ask questions.
[// GUIDANCE: Attach a “Disclosure Schedule” if extensive or procedure-specific disclosures exceed space limits.]
3.3 Voluntary Consent & Withdrawal Rights
(a) Voluntary Decision. Patient affirms that consent is given voluntarily without coercion.
(b) Right to Withdraw. Patient may revoke consent orally or in writing at any time before or during Treatment, subject to emergent circumstances.
(c) Consequences of Withdrawal. Patient acknowledges that withdrawal may result in termination of Treatment and additional medical or financial consequences described in Section 6.
3.4 Financial Responsibility
(a) Insurance Assignment. Patient assigns insurance benefits to Provider as permitted by law.
(b) Out-of-Pocket Obligations. Patient remains responsible for deductibles, co-payments, coinsurance, non-covered services, and other charges.
(c) Default Interest & Collection. Balances more than “[XX]” days past due accrue interest at “[X]% per annum” and may be referred to collections; see Section 6.
3.5 Conditions Precedent & Subsequent
(a) Pre-Procedure Instructions. Compliance with fasting, medication management, and other pre-procedure directives is a condition precedent to Treatment.
(b) Post-Treatment Compliance. Failure to adhere to prescribed post-treatment care may relieve Provider of further responsibility to the extent permitted by law.
4. REPRESENTATIONS & WARRANTIES
4.1 Provider Representations
(a) Licensure & Accreditation. Provider and participating clinicians are duly licensed in New York and maintain requisite certifications.
(b) Standard of Care. Provider will perform Treatment in accordance with prevailing professional standards.
4.2 Patient Representations
(a) Accuracy of Information. Patient has disclosed complete and accurate medical history, medications, allergies, and other material facts.
(b) Capacity. Patient affirms Capacity to consent or, if lacking, that an Authorized Representative executes this Agreement with full authority.
(c) Understanding. Patient has had all questions answered to satisfaction and understands the disclosed information.
4.3 Survival. Representations and warranties survive completion or termination of Treatment to the extent necessary to enforce this Agreement.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants
(a) Follow-Up Care. Patient will adhere to Provider’s post-treatment instructions and attend follow-up appointments.
(b) Cooperation. Patient will cooperate in billing, insurance, and administrative processes, including executing additional documents reasonably requested.
5.2 Provider Covenants
(a) Confidentiality. Provider will protect Patient’s Protected Health Information in compliance with HIPAA and applicable state privacy laws.
(b) Notice of Material Changes. Provider will notify Patient of any material change in Treatment plan where practicable.
6. DEFAULT & REMEDIES
6.1 Patient Default
(a) Non-Payment. Failure to pay undisputed charges within “[XX]” days of invoice constitutes a default.
(b) Non-Compliance. Material failure to comply with Section 5.1 constitutes a default.
6.2 Provider Remedies
Provider may (i) suspend non-emergency services; (ii) pursue collections; and (iii) recover reasonable attorney’s fees and costs incurred in enforcement.
6.3 Provider Default
Material breach of Section 4.1(b) entitles Patient to pursue remedies available under Governing Law, subject to Section 7 limitations.
6.4 Cure Period
Except in emergencies, the non-breaching party shall provide written notice and a “[10]-day” opportunity to cure before enforcing remedies.
7. RISK ALLOCATION
7.1 Indemnification
Patient shall indemnify, defend, and hold harmless Provider from losses arising out of (i) inaccurate or omitted Patient information, or (ii) Patient’s breach of this Agreement, except to the extent caused by Provider’s negligence or willful misconduct (“Informed Consent Protection”).
7.2 Limitation of Liability
(a) Statutory Limits. Nothing herein waives or limits any right or remedy under New York medical malpractice law, including caps on noneconomic damages where applicable.
(b) Exclusion of Certain Damages. Neither party shall be liable for incidental, consequential, special, or punitive damages except as mandated by Governing Law.
7.3 Force Majeure / Emergency Deviation
Provider may deviate from the Treatment plan without further consent if emergent circumstances threaten life or substantial bodily function and obtaining consent is impracticable.
8. DISPUTE RESOLUTION
8.1 Forum Selection. Subject to Section 8.2, all actions shall be brought exclusively in the state courts of competent jurisdiction located in “[COUNTY], New York.”
8.2 Optional Arbitration. If both parties initial below, any dispute shall be resolved by binding arbitration under the Commercial Arbitration Rules of the American Arbitration Association, held in “[CITY], New York,” and judgment on the award may be entered in any court of competent jurisdiction.
Patient Initials: _ Provider Initials: ___
8.3 Jury Trial Waiver. [OPTIONAL] By initialing, Patient voluntarily waives the constitutional right to a trial by jury for any dispute arising under this Agreement, to the extent such waiver is enforceable under New York law.
Patient Initials: _ Provider Initials: ___
8.4 Injunctive Relief. Either party may seek limited injunctive relief to preserve the status quo pending final resolution.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers. Must be in writing and signed by both parties; no oral modification is effective.
9.2 Assignment. Patient may not assign rights or delegate duties without Provider’s prior written consent. Provider may assign receivables to a financing or billing entity.
9.3 Severability. Invalid or unenforceable provisions shall be reformed to the minimum extent necessary; remaining provisions remain in full force.
9.4 Entire Agreement. This Agreement, including any attachments and Disclosure Schedules, constitutes the complete understanding, superseding all prior discussions.
9.5 Counterparts; Electronic Signatures. Executed in multiple counterparts, each deemed an original. Signatures transmitted electronically (e.g., DocuSign) are binding.
9.6 Notices. Notices under this Agreement shall be in writing and delivered via (i) certified mail, return receipt requested; (ii) nationally recognized courier; or (iii) secure electronic means with confirmation, to the addresses set forth below.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties execute this Agreement as of the Effective Date.
A. Patient / Authorized Representative
Signature: ____
Name: ______
Relationship (if not Patient): _
Address: ____
Date: ________
B. Provider
Authorized Clinician Signature: __
Name & Credentials: ___
Title: _____
Date: _________
C. Interpreter (if applicable)
I certify that I have accurately translated the information and questions between Provider and Patient.
Signature: ____
Name & Language: ___
Date: _____
D. Witness (if required by facility policy)
Signature: ______
Name: ______
Date: _________
E. Notary Acknowledgment (optional / if required for certain procedures)
State of New York )
County of _) ss.:
On the _ day of _, 20_, before me, the undersigned, a Notary Public in and for said state, personally appeared ___, proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the foregoing instrument and acknowledged that s/he executed the same.
Notary Public Signature: ___
My Commission Expires: _____
[// GUIDANCE:
1. Attach ancillary documents as needed: procedure-specific risk sheets, HIPAA Notice of Privacy Practices acknowledgment, advance directive forms, and financial policy.
2. Review Section 8 arbitration and jury waiver clauses carefully—New York courts scrutinize such waivers for clarity and voluntariness.
3. Confirm that disclosures in Section 3.2 meet facility policy and the “reasonable practitioner” and “reasonable patient” standards under N.Y. Pub. Health Law § 2805-d.
4. For minors, obtain parental/guardian consent unless statutory exceptions apply (e.g., reproductive health, mental health, substance abuse).
5. Maintain executed originals or secure electronic records in the patient’s medical record per 10 N.Y.C.R.R. § 405.10.]