OHIO PATIENT CONSENT TO MEDICAL TREATMENT

(Comprehensive Template – For Attorney Customization)

[// GUIDANCE: This template is drafted to satisfy Ohio’s informed-consent statute (Ohio Rev. Code Ann. § 2317.54) and current professional standards. All bracketed items must be customized. Remove guidance comments before finalization.]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default, Revocation & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1.1 Title. Patient Consent to Medical Treatment (the “Consent”).

1.2 Parties.
(a) “Patient”: [PATIENT LEGAL NAME], DOB __ / __ /_, residing at [ADDRESS].
(b) “Provider”: [PHYSICIAN / ADVANCED PRACTICE PROVIDER NAME], Ohio medical license no. _____, practicing at [FACILITY NAME & ADDRESS] (collectively with its employees and agents, the “Provider”).

1.3 Recitals.
WHEREAS, Patient seeks to undergo the medical treatment described herein (the “Treatment”); and
WHEREAS, Provider is willing to render such Treatment subject to Patient’s informed, voluntary, and written consent;

NOW, THEREFORE, in consideration of the mutual promises herein and other good and valuable consideration, the parties agree as follows.

1.4 Effective Date. This Consent is effective on the date of Patient’s (or Authorized Representative’s) signature below (the “Effective Date”).

1.5 Governing Law. This Consent is governed by the medical-consent laws of the State of Ohio and applicable federal law.

II. DEFINITIONS

For purposes of this Consent, the following terms have the meanings set forth below:

“Authorized Representative” – an individual legally empowered to act on Patient’s behalf, including a parent/guardian of a minor, holder of a valid health-care power of attorney, or court-appointed guardian.

“Capacity” – the ability of Patient to understand the nature and consequences of the Treatment and to make an informed decision, as determined by Provider in accordance with professional standards and Ohio law.

“Emergency” – a circumstance in which delay in rendering Treatment would pose an imminent threat to Patient’s life or a serious risk of substantial impairment.

“HIPAA” – the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, including 45 C.F.R. Parts 160 & 164.

“Material Risks” – those risks that a reasonable person in Patient’s position would consider significant when deciding whether to consent to the Treatment.

“Procedure” – the specific medical, surgical, or diagnostic intervention identified in Section III.

“Treatment” – collectively, the Procedure and all related services, anesthesia, medications, post-operative care, and ancillary services described herein.

III. OPERATIVE PROVISIONS

3.1 Description of Treatment.
(a) Procedure: [DETAILED DESCRIPTION OF PROPOSED PROCEDURE].
(b) Purpose & Expected Benefits: [DESCRIBE].
(c) Anticipated Recovery & Follow-Up: [DESCRIBE].

3.2 Disclosure of Material Information.
(a) Material Risks: [LIST RISKS] including but not limited to ____.
(b) Alternatives (including opting to decline Treatment): [LIST].
(c) Prognosis Without Treatment: [DESCRIBE].

3.3 Patient Acknowledgments. Patient (or Authorized Representative) confirms that:
(i) Provider has explained the matters set forth in Sections 3.1–3.2 in a manner Patient understands;
(ii) Patient had the opportunity to ask questions, all of which were answered satisfactorily; and
(iii) Patient voluntarily consents to proceed.

3.4 Financial Responsibility. Patient agrees to pay all charges not covered by insurance and authorizes Provider to bill insurance directly. [// GUIDANCE: Insert detailed payment terms if facility policy requires.]

3.5 Conditions Precedent. Provider’s obligation to perform the Treatment is conditioned upon:
(a) verification of Capacity (Section IV.2);
(b) receipt of required pre-operative labs/tests; and
(c) absence of material change in Patient’s medical condition.

IV. REPRESENTATIONS & WARRANTIES

4.1 Provider Representations. Provider represents that:
(a) Provider holds all licenses, certifications, and privileges required under Ohio law to perform the Treatment;
(b) Provider will perform the Treatment in accordance with the prevailing standard of care; and
(c) Provider maintains professional liability insurance meeting Ohio statutory minimums.

4.2 Patient Representations. Patient represents that:
(a) Patient possesses Capacity, or, if lacking Capacity, the signatory is an Authorized Representative;
(b) all medical history disclosed to Provider is complete and accurate;
(c) Patient is not relying on any statement not contained herein; and
(d) Patient has not been offered, nor received, any inducement to consent.

4.3 Survival. The representations and warranties in this Section IV survive the completion of Treatment.

V. COVENANTS & RESTRICTIONS

5.1 Patient Covenants. Patient shall:
(a) follow Provider’s pre- and post-operative instructions;
(b) disclose promptly any adverse symptoms; and
(c) execute additional HIPAA-compliant authorizations if further disclosure of protected health information is necessary for continuity of care.

5.2 Provider Covenants. Provider shall:
(a) maintain Patient’s medical records in accordance with HIPAA and Ohio Rev. Code Ann. § 3701.74 et seq.;
(b) obtain additional consent for any material deviation from the Treatment plan, except in an Emergency; and
(c) notify Patient of any significant change in Provider’s licensure status.

VI. DEFAULT, REVOCATION & REMEDIES

6.1 Patient Revocation. Patient may revoke this Consent at any time prior to induction of anesthesia or commencement of the Procedure by providing verbal or written notice to Provider. Revocation after commencement shall be subject to medical feasibility and professional responsibility considerations.

6.2 Events of Default.
(a) Patient default: failure to provide accurate medical information, non-payment, or breach of Section V.
(b) Provider default: material deviation from the standard of care or breach of Section V.2.

6.3 Remedies.
(a) Patient Remedies: pursue statutory and common-law claims, subject to Section VII (Risk Allocation).
(b) Provider Remedies: suspend or terminate Treatment (when medically safe), recover unpaid charges plus interest at __ % per annum, and seek equitable relief to protect confidential information.

6.4 Attorney Fees. In any action arising out of this Consent, the prevailing party is entitled to reasonable attorney fees, costs, and expenses, unless prohibited by applicable law.

VII. RISK ALLOCATION

7.1 Indemnification. Patient shall indemnify, defend, and hold harmless Provider from any claim, damage, or loss arising out of Patient’s breach of representations in Section IV.2 or Patient’s failure to follow Provider’s instructions, except to the extent caused by Provider’s negligence or willful misconduct (“Informed-Consent Protection”).

7.2 Limitation of Liability. Provider’s liability for non-economic damages is limited to the caps set forth in Ohio Rev. Code Ann. § 2323.43, and any successor statute, and in no event shall Provider be liable for exemplary or punitive damages except as expressly permitted by Ohio law (“Malpractice Limits”).

7.3 Insurance. Provider maintains professional liability coverage of not less than $[AMOUNT] per claim and $[AMOUNT] aggregate.

7.4 Force Majeure. Neither party is liable for delay or failure to perform caused by events beyond its reasonable control, excluding payment obligations.

VIII. DISPUTE RESOLUTION

8.1 Governing Law. This Consent is governed by the laws of the State of Ohio without regard to conflict-of-law principles.

8.2 Forum Selection. Subject to Section 8.3, the parties irrevocably submit to the exclusive jurisdiction of the state courts located in [COUNTY], Ohio.

8.3 Optional Arbitration.
☐ Patient elects arbitration under the Ohio Uniform Arbitration Act, Ohio Rev. Code Ann. Chapter 2711.
☐ Patient declines arbitration and prefers resolution in state court.

8.4 Jury Trial. Patient acknowledges the constitutional right to a jury trial and does not waive this right unless arbitration is elected in Section 8.3.

8.5 Injunctive Relief. Nothing herein restricts a party from seeking temporary or preliminary injunctive relief, provided such relief is limited to preserving the status quo pending final resolution.

IX. GENERAL PROVISIONS

9.1 Amendments. Any amendment must be in writing and signed by both parties (and, where applicable, by the Authorized Representative).

9.2 Waiver. Failure to enforce any provision is not a waiver of future enforcement.

9.3 Assignment. Patient may not assign rights or delegate duties without Provider’s prior written consent. Provider may assign payment rights to billing agents or successors in interest.

9.4 Severability. If any provision is held unenforceable, it shall be modified to the minimum extent necessary, and the remainder remains in full force.

9.5 Entire Agreement. This Consent, together with any attachments listed below, constitutes the entire agreement regarding the Treatment and supersedes all prior oral or written communications.

9.6 Counterparts; Electronic Signatures. This Consent may be executed in counterparts and by electronic signature, each of which is deemed an original.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the parties execute this Consent as of the Effective Date.

A. Patient / Authorized Representative

Signature: _____
Print Name: ____
Relationship (if not Patient): __
Date: ___ / ___ / ______

B. Provider

Signature: _____
Print Name: ____
Title: ______
Date: ___ / ___ / ______

C. Witness (Optional but Recommended)

Signature: _____
Print Name: ____
Date: ___ / ___ / ______

D. Interpreter Certification (If Applicable)

I certify that I accurately translated the contents of this Consent to the Patient/Authorized Representative.
Signature: _____
Print Name & Language: __
Date: ___ / ___ / ___

ATTACHMENTS (CHECK ALL THAT APPLY)

☐ Attachment A: Procedure-Specific Risk Disclosure Sheet
☐ Attachment B: Financial Agreement & Insurance Assignment
☐ Attachment C: HIPAA Authorization (45 C.F.R. § 164.508 compliant)

[// GUIDANCE: 1) Retain the signed original in the medical record for at least the period required by Ohio Admin. Code 3701-83-11. 2) Provide a copy to Patient immediately upon execution. 3) For minors, attach proof of guardianship or custody order.]