INFORMED CONSENT TO MEDICAL TREATMENT
(Texas – Comprehensive Form)
[// GUIDANCE: This template is drafted to satisfy Texas statutory informed-consent requirements (Tex. Civ. Prac. & Rem. Code ch. 74) and common-law capacity standards. Customize bracketed fields before use and attach the Medical Disclosure Panel risk list(s) applicable to the proposed Treatment.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title & Parties
THIS INFORMED CONSENT TO MEDICAL TREATMENT (this “Consent”) is made and entered into as of [EFFECTIVE DATE] (the “Effective Date”) by and between:
a. Patient: [PATIENT LEGAL NAME], DOB [MM/DD/YYYY], residing at [ADDRESS]; and
b. Provider: [LICENSED PHYSICIAN OR PRACTICE NAME], a Texas-licensed health-care provider, NPI [NUMBER], with its principal place of business at [ADDRESS];
(each, a “Party,” and together, the “Parties”).
1.2 Recitals
WHEREAS, Patient seeks and Provider agrees to render [DESCRIBE TREATMENT/PROCEDURE] (“Treatment”) at [FACILITY NAME] in the State of Texas; and
WHEREAS, the Parties desire to set forth their respective rights and obligations concerning such Treatment, consistent with Texas informed-consent standards;
NOW, THEREFORE, for good and valuable consideration, the adequacy and receipt of which are hereby acknowledged, the Parties agree as follows:
2. DEFINITIONS
For ease of reference, the following capitalized terms shall have the meanings set forth below. Terms defined in the singular include the plural and vice-versa.
“Authorized Representative” – An individual authorized under Texas law (e.g., Tex. Fam. Code ch. 32; Tex. Health & Safety Code §§166.002–.166) to act on a Patient’s behalf.
“Disclosure Panel Lists” – The then-current List A and List B adopted by the Texas Medical Disclosure Panel pursuant to Tex. Civ. Prac. & Rem. Code § 74.103.
“Healthcare Team” – All physicians, residents, nurses, technicians, and other personnel involved in Patient’s care.
“Indemnified Claim” – Any third-party claim arising out of (i) Patient’s breach of this Consent or (ii) Patient’s failure to follow post-Treatment instructions, excluding Provider’s professional negligence.
“Informed Consent” – A knowing and voluntary approval of Treatment after disclosure of material risks, alternatives, and expected benefits consistent with § 74.102.
“Protected Health Information” or “PHI” – Has the meaning ascribed in 45 C.F.R. § 160.103.
“Treatment” – The medical or surgical procedure(s) described in Section 3.1, together with ancillary services (e.g., anesthesia, radiology, pathology) reasonably necessary thereto.
3. OPERATIVE PROVISIONS
3.1 Description of Treatment. Patient hereby authorizes Provider and the Healthcare Team to perform [DETAILED DESCRIPTION OF PROCEDURE, BODY SITE, AND PURPOSE] including any unforeseen but necessary procedures that, in Provider’s professional judgment, are integral to the originally-intended Treatment and consented to herein.
3.2 Disclosure of Risks & Alternatives.
a. Provider has explained, and Patient acknowledges receipt and understanding of, the material risks listed on Schedule 1 (incorporating applicable Disclosure Panel Lists) and any additional patient-specific risks.
b. Provider has discussed reasonable therapeutic alternatives (including non-treatment) and their material risks and benefits.
3.3 Benefits & Prognosis. Provider has communicated the expected benefits of Treatment and the reasonable likelihood of achieving such benefits. Provider has made no guarantee regarding outcomes.
3.4 Anesthesia & Sedation. Patient consents to the administration of [LOCAL/GENERAL/CONSCIOUS SEDATION] anesthesia by qualified personnel. Associated risks have been disclosed.
3.5 Blood & Biologic Products. If Provider determines that the use of blood or blood products is medically necessary, Patient [CHECK ONE: ☐ CONSENTS | ☐ REFUSES] transfusion, subject to emergency exception under applicable law.
3.6 Capacity & Voluntariness. Patient represents that Patient (or Authorized Representative) is of sound mind, not under duress, and legally competent to grant Informed Consent.
3.7 Right to Withdraw. Patient may revoke this Consent at any time prior to commencement of Treatment by providing written or verbal notice to Provider; however, Patient remains liable for services rendered and non-refundable costs incurred to that point.
3.8 Financial Responsibility. Patient accepts responsibility for all charges not covered by insurance and understands that Provider may assist, but is not responsible for, insurance reimbursement.
3.9 Telemedicine (If Applicable). Patient consents to the use of telemedicine technologies consistent with Tex. Occ. Code ch. 111 and acknowledges associated limitations.
3.10 Photography & Recording. Patient [CHECK ONE: ☐ CONSENTS | ☐ WITHHOLDS CONSENT] to medical photography/audio-visual recording for treatment, education, and quality-assurance purposes, subject to de-identification of PHI unless separately authorized.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient Reps & Warranties. Patient (or Authorized Representative) warrants that:
a. All medical history provided is complete and accurate;
b. Patient has had the opportunity to ask questions and has received satisfactory answers;
c. Patient understands that failure to follow Provider’s instructions may adversely affect outcomes.
4.2 Provider Reps & Warranties. Provider warrants that:
a. Provider holds all licenses, permits, and certifications required under Texas law;
b. Treatment will be rendered in accordance with the prevailing professional standard of care;
c. Provider has disclosed any financial interests that may create a conflict per 42 C.F.R. pt. 411 (Stark Law) and Tex. Occ. Code ch. 102.
4.3 Survival. The representations and warranties in this Section survive completion of Treatment to the extent necessary to enforce the Parties’ rights hereunder.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants. Patient shall:
a. Follow Provider’s pre- and post-Treatment instructions;
b. Promptly report any unexpected reactions or complications;
c. Provide payment in accordance with Section 3.8.
5.2 Provider Covenants. Provider shall maintain professional liability insurance in an amount at least equal to the statutory caps referenced in Section 7.2.
6. DEFAULT & REMEDIES
6.1 Patient Default. Material breach by Patient of Section 5.1 constitutes default. Upon default, Provider may:
a. Terminate the physician-patient relationship following reasonable notice and emergency-care obligations; and
b. Pursue collection of outstanding fees, inclusive of interest at the lesser of 18% per annum or the maximum rate allowed by Tex. Fin. Code § 304.002.
6.2 Provider Default. Material breach by Provider of Section 5.2 constitutes default. Patient may pursue statutory remedies for medical negligence; however, nothing in this Consent waives Provider’s statutory defenses or caps.
6.3 Notice & Cure. The non-defaulting Party shall provide written notice specifying the default. The defaulting Party shall have ten (10) days to cure, unless impracticable due to the nature of the breach.
6.4 Attorneys’ Fees. The prevailing Party in any action to enforce this Consent is entitled to reasonable attorneys’ fees and costs.
7. RISK ALLOCATION
7.1 Indemnification. Patient shall indemnify, defend, and hold harmless Provider and the Healthcare Team from and against any Indemnified Claim, except to the extent caused by Provider’s professional negligence or willful misconduct.
7.2 Limitation of Liability. Recovery for any claim sounding in health-care liability against Provider is subject to the damage limitations set forth in Tex. Civ. Prac. & Rem. Code § 74.301 (noneconomic damages cap) and related provisions (“Malpractice Limits”).
7.3 Force Majeure. Neither Party shall be liable for delay or failure in performance (excluding payment obligations) due to acts of God, governmental action, epidemic, or other causes beyond the Party’s reasonable control.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Consent and any dispute arising hereunder shall be governed by the laws of the State of Texas without regard to conflict-of-laws principles.
8.2 Forum Selection. The Parties submit to the exclusive jurisdiction of the state courts located in [COUNTY], Texas (“State Court”).
8.3 Optional Arbitration.
a. Patient may elect binding arbitration pursuant to Tex. Civ. Prac. & Rem. Code ch. 171 by initialing below:
Patient Initials: __ Date: ____
b. If elected, a single arbitrator with at least five (5) years’ experience in health-care law shall conduct arbitration under the Commercial Arbitration Rules of the American Arbitration Association.
8.4 Jury Trial. The Parties acknowledge the constitutional right to trial by jury and agree that no clause herein constitutes a waiver of that right.
8.5 Injunctive Relief. Nothing herein limits either Party’s right to seek provisional or injunctive relief to protect PHI or prevent irreparable harm.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers. Any amendment or waiver must be in writing and signed by both Parties.
9.2 Assignment. Neither Party may assign its rights or delegate its duties without the other Party’s prior written consent, except Provider may assign to a successor practice entity.
9.3 Successors & Assigns. This Consent binds and benefits the Parties and their permitted successors and assigns.
9.4 Severability. If any provision is held unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to make it enforceable.
9.5 Entire Agreement. This Consent, together with any schedules, constitutes the entire agreement concerning its subject matter and supersedes all prior oral or written understandings.
9.6 Counterparts; Electronic Signatures. This Consent may be executed in counterparts, each of which is deemed an original. Signatures transmitted via facsimile, PDF, or secure electronic signature platform constitute original signatures for all purposes.
9.7 HIPAA Notice. Patient acknowledges receipt of Provider’s Notice of Privacy Practices in compliance with 45 C.F.R. § 164.520.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Parties have executed this Consent as of the Effective Date.
10.1 Patient / Authorized Representative
| Signature | Name (print) | Relationship (if representative) | Date |
|---|---|---|---|
| ______ | ______ | ______ | ____ |
10.2 Provider
| Signature | Name & Credentials (print) | Date |
|---|---|---|
| ______ | ______ | ____ |
10.3 Witness (recommended)
| Signature | Name (print) | Date |
|---|---|---|
| ______ | ______ | ____ |
Schedule 1 – Material Risks & Alternatives
[// GUIDANCE: Attach the relevant Texas Medical Disclosure Panel List A procedure list or, if Treatment is on List B/not listed, provide a tailored narrative disclosure of material risks, frequency, severity, and alternatives.]
[// GUIDANCE: Obtain legal review before implementation, ensure alignment with facility policies, and retain executed forms in the patient’s medical record for at least the minimum period required under Tex. Admin. Code tit. 22, § 165.1.]