PATIENT CONSENT TO MEDICAL TREATMENT
(Commonwealth of Pennsylvania)
[// GUIDANCE: This form is drafted to comply with Pennsylvania’s Medical Care Availability and Reduction of Error Act (“MCARE Act”) informed-consent requirements, 40 P.S. § 1303.504, as well as general Pennsylvania contract principles. Customize bracketed terms before use.]
I. DOCUMENT HEADER
A. Parties
This Patient Consent to Medical Treatment (the “Consent”) is entered into as of [EFFECTIVE DATE] (the “Effective Date”) by and between:
- Patient: [PATIENT LEGAL NAME], date of birth [DOB], residing at [PATIENT ADDRESS] (the “Patient”); and
- Provider: [LEGAL NAME OF PHYSICIAN / PRACTICE], a Pennsylvania-licensed [PHYSICIAN / HEALTH CARE PRACTICE] with its principal place of business at [PROVIDER ADDRESS] (the “Provider”).
B. Recitals
WHEREAS, the Patient seeks to undergo the medical treatment, procedure, or course of care described herein (the “Procedure”); and
WHEREAS, the Provider is willing to perform or supervise the Procedure subject to the Patient’s informed, voluntary, and written consent;
NOW, THEREFORE, in consideration of the mutual promises herein and other good and valuable consideration, the sufficiency of which are hereby acknowledged, the parties agree as follows.
II. DEFINITIONS
For purposes of this Consent, the following capitalized terms have the meanings set forth below:
“Authorized Representative” – a person legally authorized under Pennsylvania law to act on behalf of the Patient, including but not limited to a parent of a minor, legal guardian, or holder of a valid health-care power of attorney.
“Facility” – the hospital, ambulatory surgical center, medical office, or other licensed location where the Procedure is to be performed.
“Known Material Risks” – those risks that a reasonably prudent patient would deem significant in deciding whether to undergo the Procedure, including risks disclosed in writing or orally pursuant to 40 P.S. § 1303.504.
“Protected Health Information” or “PHI” – individually identifiable health information protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its implementing regulations.
“Procedure” – the specific medical treatment, operation, diagnostic test, or other health-care service more fully described in Section 3.1 below.
III. OPERATIVE PROVISIONS
3.1 Description of Procedure
The Procedure for which consent is given is:
[DETAILED CLINICAL DESCRIPTION, CPT/ICD CODES IF APPLICABLE].
3.2 Disclosures Provided
Prior to execution of this Consent, the Provider has, in compliance with 40 P.S. § 1303.504, provided and explained to the Patient, in a manner understandable to a reasonably prudent person:
a. The nature and purpose of the Procedure;
b. The Known Material Risks and expected benefits;
c. Reasonable alternatives and their risks and benefits;
d. The identity and professional status of individuals performing significant portions of the Procedure; and
e. The anticipated recovery time and post-Procedure requirements.
3.3 Patient Acknowledgements
The Patient (or Authorized Representative) hereby acknowledges and agrees that:
a. All disclosures listed in Section 3.2 were received and comprehended;
b. All questions have been answered satisfactorily;
c. No guarantee or assurance has been made as to results or cure;
d. Consent is voluntary and may be withdrawn at any time prior to commencement of the Procedure;
e. Refusal to consent may result in postponement or cancellation of the Procedure.
3.4 Financial Responsibility
The Patient remains responsible for all charges not covered by insurance, including co-payments, deductibles, and non-covered services. Non-payment constitutes a Patient Default under Section 6.1.
3.5 Authorization for Ancillary Services
The Patient authorizes the Provider and Facility to order and administer any ancillary services reasonably necessary or advisable during the Procedure, including anesthesia, laboratory tests, imaging, and blood products.
3.6 Telemedicine (If Applicable)
[INCLUDE / DELETE] The Patient consents to receive portions of the health-care services via telemedicine consistent with 49 Pa. Code Ch. 17.
3.7 Photographs, Video, and Specimens
The Patient grants permission for clinical photographs or recordings exclusively for treatment, payment, or health-care operations, unless Patient initials here to withhold consent: ______.
IV. REPRESENTATIONS & WARRANTIES
4.1 Patient Representations
a. Capacity: The Patient possesses legal capacity to consent, or an Authorized Representative executes this Consent on the Patient’s behalf pursuant to applicable Pennsylvania law.
b. Accuracy: All medical history and information supplied to the Provider is complete and accurate to the best of Patient’s knowledge.
4.2 Provider Representations
a. Licensure: The Provider and all assisting personnel hold current, unrestricted Pennsylvania licenses or certifications required to perform their respective duties.
b. Standard of Care: The Procedure shall be performed consistent with prevailing professional standards and all applicable laws and regulations.
4.3 Survival
The representations and warranties in this Article IV survive performance of the Procedure for the applicable statute-of-limitations period.
V. COVENANTS & RESTRICTIONS
5.1 Patient Covenants
a. Compliance: The Patient shall comply with all pre- and post-Procedure instructions.
b. Cooperation: The Patient shall provide timely, accurate information and notify the Provider of any post-Procedure complications.
5.2 Provider Covenants
Provider shall maintain in-force professional liability insurance meeting or exceeding the MCARE Fund requirements.
VI. DEFAULT & REMEDIES
6.1 Events of Patient Default
a. Non-payment under Section 3.4;
b. Material breach of Section 5.1.
6.2 Notice and Cure
The Provider shall give written notice of default; the Patient shall have ten (10) calendar days to cure monetary defaults and a commercially reasonable period to cure non-monetary defaults.
6.3 Remedies
Upon uncured default, the Provider may pursue any remedies available at law or equity, including collection of amounts due, reasonable attorneys’ fees, and court costs.
VII. RISK ALLOCATION
7.1 Indemnification – Informed Consent Protection
To the fullest extent permitted by Pennsylvania law, the Patient shall indemnify and hold harmless the Provider, Facility, and their respective employees and agents from any loss, claim, or expense arising out of (a) the Patient’s breach of this Consent, or (b) materially inaccurate or omitted medical information supplied by the Patient, except to the extent caused by the Provider’s negligence or willful misconduct.
[// GUIDANCE: Pennsylvania law prohibits indemnification for a provider’s own negligence in a medical context. The above carve-out preserves enforceability.]
7.2 Limitation of Liability
Nothing herein limits liability for professional negligence (medical malpractice). All non-malpractice, incidental, or consequential damages are limited to the amount actually paid by the Patient for the Procedure. This Section 7.2 is intended to operate within Pennsylvania public-policy constraints and shall be construed accordingly.
7.3 Force Majeure
Neither party shall be liable for delay or failure to perform any non-medical obligation under this Consent due to causes beyond its reasonable control, including acts of God, governmental orders, or public health emergencies.
VIII. DISPUTE RESOLUTION
8.1 Governing Law
This Consent shall be governed by and construed in accordance with the substantive laws of the Commonwealth of Pennsylvania, without regard to conflict-of-laws principles.
8.2 Forum Selection
Exclusive jurisdiction and venue shall lie in the Court of Common Pleas of [COUNTY], Pennsylvania, or such other Pennsylvania state court of competent jurisdiction.
8.3 Optional Binding Arbitration
[INCLUDE IF INITIALLED] ___ Patient ___ Provider
If both parties initial above, any dispute arising out of or related to this Consent or the Procedure (other than claims seeking solely injunctive or equitable relief) shall be resolved by binding arbitration under the Pennsylvania Uniform Arbitration Act, 42 Pa. Cons. Stat. §§ 7301 et seq., before a single arbitrator mutually selected, with the arbitrator’s award enforceable in any court of competent jurisdiction.
8.4 Jury Trial Waiver
[OPTIONAL—STRIKE IF NOT DESIRED] The parties knowingly and voluntarily waive any constitutional and statutory right to trial by jury in any litigation arising out of this Consent, to the extent such waiver is permissible under Pennsylvania law.
8.5 Injunctive Relief
Either party may seek temporary, preliminary, or permanent injunctive relief in a court of competent jurisdiction to protect PHI or enforce post-Procedure payment obligations notwithstanding Section 8.3.
IX. GENERAL PROVISIONS
9.1 Amendments and Waivers
Any amendment to this Consent must be in writing and signed by both parties. Waiver of any breach shall not constitute waiver of any subsequent breach.
9.2 Assignment
Neither party may assign or delegate its rights or obligations hereunder without prior written consent of the other party, except that the Provider may assign billing rights to a qualified billing service or factor.
9.3 Severability
If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to achieve its intent.
9.4 Integration
This Consent constitutes the entire agreement between the parties regarding the subject matter and supersedes all prior or contemporaneous oral or written communications.
9.5 Electronic Signatures
Signatures transmitted via facsimile, PDF, or secure electronic signature platform shall be deemed original.
9.6 Counterparts
This Consent may be executed in one or more counterparts, each of which shall be deemed an original but all of which together constitute one instrument.
X. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties hereto have executed this Consent as of the Effective Date.
| PATIENT / AUTHORIZED REPRESENTATIVE | DATE | TIME |
|---|---|---|
| _________ Name: [PRINT NAME] Relationship (if not Patient): [RELATIONSHIP] |
______ | ______ |
| PROVIDER | LICENSE NO. | DATE | TIME |
|---|---|---|---|
| _________ Name: [PHYSICIAN NAME, M.D./D.O.] |
[#] | ______ | ______ |
| WITNESS (Optional) | DATE |
|---|---|
| _________ Name: [PRINT NAME] |
______ |
[Notary Acknowledgment if required by Facility policy]
[// GUIDANCE:
1. Attach any written risk disclosures, brochures, or educational materials as Exhibit A and reference them in Section 3.2.
2. For minors or incapacitated adults, obtain signature of Authorized Representative and document basis of authority.
3. Retain the executed Consent in the Patient’s medical record for the period mandated by 49 Pa. Code § 16.95.
4. Review annually for regulatory updates, particularly any amendments to the MCARE Act or HIPAA.]