PATIENT CONSENT TO MEDICAL TREATMENT AND ACKNOWLEDGMENT OF INFORMED CONSENT
(Washington State – Comprehensive Form)
[// GUIDANCE: This template is intentionally robust to satisfy Washington’s stringent informed-consent requirements under Wash. Rev. Code Ann. § 7.70.050 and § 7.70.065, and to provide strong defensive documentation for the Provider. Delete any provisions that are unnecessary for the contemplated treatment.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1. Scope of Treatment
3.2. Informed Consent Disclosures
3.3. Patient Acknowledgments & Elections
3.4. Consideration - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
Title: Patient Consent to Medical Treatment and Acknowledgment of Informed Consent
Effective Date: [EFFECTIVE DATE]
Health Care Provider: [LEGAL NAME OF FACILITY / PRACTICE] (“Provider”)
Patient: [PATIENT LEGAL NAME], date of birth [DOB] (“Patient”)
Authorized Representative (if applicable): [REPRESENTATIVE NAME], relationship to Patient: [RELATIONSHIP] (“Representative”)
Recitals
A. Provider is duly licensed and qualified under Washington law to render the Treatment (as defined below).
B. Patient (or Representative) desires to receive the Treatment from Provider and is willing to grant informed consent subject to the terms of this Agreement (the “Consent Form”).
C. In consideration of the mutual promises herein, the parties agree as follows.
2. DEFINITIONS
For purposes of this Consent Form, the following terms have the meanings set forth below:
“Capacity” means the ability to understand the nature, consequences, and risks of the Treatment, consistent with Wash. Rev. Code Ann. § 7.70.065.
“Complication” means any known or reasonably foreseeable adverse event associated with the Treatment.
“Disclosure Materials” means the written, verbal, and visual information supplied by Provider to Patient describing the Treatment, alternatives, material risks, benefits, and Complications.
“Emergency” means a situation in which immediate treatment is necessary to prevent death or serious harm and obtaining informed consent is impracticable.
“Health Care Provider” or “Provider” has the meaning assigned under Wash. Rev. Code Ann. § 7.70.020.
“Informed Consent” means the consent required under Wash. Rev. Code Ann. § 7.70.050, obtained after the disclosures mandated therein.
“Procedure” or “Treatment” means the medical service(s) described in Section 3.1.
“Representative” means a person authorized under Wash. Rev. Code Ann. § 7.70.065 to provide consent on behalf of a Patient lacking Capacity.
3. OPERATIVE PROVISIONS
3.1 Scope of Treatment
Provider will perform the following Treatment on or after the Effective Date:
• [DETAILED DESCRIPTION OF PROCEDURE, INCLUDING BODY PART(S) AND METHOD]
• Anticipated date(s) of service: [DATE(S)]
• Treating clinician(s): [NAME(S) & LICENSE NUMBERS]
3.2 Informed Consent Disclosures
Provider affirms that, prior to execution of this Consent Form, the following were disclosed to Patient in a manner consistent with professional practice standards and Wash. Rev. Code Ann. § 7.70.050:
a. Nature and purpose of the Treatment;
b. Material risks and Complications specific to the Patient;
c. Reasonable alternatives and their risks and benefits, including the option of no treatment;
d. Prognosis without the Treatment;
e. Identity, credentials, and role of all treating clinicians;
f. Estimated costs and financial responsibility;
g. Provider’s ownership or financial interests in any referred facility or service, if applicable; and
h. The Patient’s right to withdraw consent at any time prior to or during the Procedure where medically feasible.
[// GUIDANCE: Attach or reference separately signed Disclosure Materials to streamline record-keeping.]
3.3 Patient Acknowledgments & Elections
Patient (or Representative) hereby:
1. Acknowledges receipt and comprehension of all Disclosure Materials;
2. Confirms opportunity to ask questions and receive satisfactory answers;
3. Affirms Capacity under RCW § 7.70.065, or states relationship of Representative and statutory basis for consent;
4. Grants Provider permission to perform the Treatment, including the administration of anesthesia and use of blood products, if applicable;
5. Elects (check one):
☐ Arbitration pursuant to Section 8.2
☐ Court litigation pursuant to Section 8.1
6. Authorizes reasonable photographs, recordings, or observation by medical trainees, subject to HIPAA-compliant de-identification, solely for treatment, education, or credentialing purposes;
7. Consents to the release of necessary medical information to insurance carriers or governmental payers for payment processing; and
8. Acknowledges receipt of the Provider’s Notice of Privacy Practices.
3.4 Consideration
Patient’s agreement to remit all applicable co-payments, deductibles, and other charges as determined by insurance or Provider’s financial policy constitutes adequate consideration for this Consent Form.
4. REPRESENTATIONS & WARRANTIES
4.1 Provider represents and warrants that:
a. Provider and each clinician possess, and will maintain, all licenses, permits, and certifications required under applicable Washington and federal law;
b. The Treatment will be performed in accordance with prevailing professional standards; and
c. Provider maintains professional liability insurance meeting or exceeding Washington’s minimum statutory requirements.
4.2 Patient/Representative represents and warrants that:
a. All medical history supplied is complete and accurate to the best of the Patient’s knowledge;
b. Patient has not withheld information regarding allergies, medications, or prior adverse reactions; and
c. Patient’s decision is voluntary and free from duress.
4.3 Survival. The representations and warranties in this Section survive completion of the Treatment for the statute of limitations period applicable under Wash. Rev. Code Ann. § 4.16.350 or successor statute.
5. COVENANTS & RESTRICTIONS
5.1 Patient covenants to:
a. Comply with pre- and post-procedure instructions;
b. Provide timely notice of any unexpected condition or adverse event;
c. Refrain from recording the Procedure without Provider’s written permission.
5.2 Provider covenants to:
a. Maintain accurate and complete medical records;
b. Notify Patient of any significant change in diagnosis, prognosis, or recommended care plan.
5.3 HIPAA & Confidentiality. Both parties shall comply with 45 C.F.R. Parts 160 & 164 and Washington’s Uniform Health Care Information Act (Wash. Rev. Code Ann. ch. 70.02).
6. DEFAULT & REMEDIES
6.1 Patient Default. Failure to pay charges when due or to follow medical instructions constitutes default. Provider may, after reasonable notice, (i) terminate the physician-patient relationship consistent with professional ethics, and/or (ii) employ collection remedies permitted by law.
6.2 Provider Default. Failure to perform the Treatment in accordance with Section 4.1 constitutes default, subject to applicable malpractice remedies.
6.3 Cure Period. The non-defaulting party shall provide written notice of default and a reasonable cure period not less than ten (10) calendar days, unless medical urgency precludes delay.
6.4 Remedies. Remedies are cumulative and include monetary damages, specific performance where appropriate, and limited injunctive relief solely to enforce confidentiality obligations.
6.5 Attorneys’ Fees. The prevailing party in any action arising under this Consent Form shall recover reasonable attorneys’ fees and costs.
7. RISK ALLOCATION
7.1 Indemnification by Patient. Patient shall indemnify and hold harmless Provider from any Losses arising out of (i) Patient’s breach of Section 4.2, or (ii) unauthorized recording or disclosure by Patient of confidential medical information, except to the extent caused by Provider’s negligence or willful misconduct.
7.2 Limitation of Liability. Except for willful misconduct, gross negligence, or violations not subject to limitation under Washington law, Provider’s aggregate liability for claims directly arising out of the Treatment shall not exceed the greater of (a) the limits of Provider’s applicable professional liability insurance, or (b) any statutory cap or limitation on medical malpractice damages enforceable under Washington law at the time of judgment. Nothing herein shall be construed to limit damages where such limitation is prohibited by Wash. Const. art. I, § 10 or other applicable law.
7.3 Insurance. Patient is advised to verify health-insurance coverage and understands that lack of coverage does not relieve financial responsibility.
7.4 Force Majeure. Neither party shall be liable for failure to perform obligations (other than payment) where performance is prevented by events beyond reasonable control, including natural disasters, strikes, or governmental orders.
8. DISPUTE RESOLUTION
8.1 Governing Law & Forum Selection. This Consent Form is governed by the laws of the State of Washington, without regard to conflict-of-law principles. Except as provided in Section 8.2, the parties submit to exclusive jurisdiction in the state courts located in [COUNTY], Washington.
8.2 Optional Binding Arbitration. If Patient elects arbitration above, any dispute arising out of or relating to the Treatment shall be resolved by confidential, binding arbitration before a single arbitrator under the Washington Arbitration Act (Wash. Rev. Code Ann. ch. 7.04A) and the then-current rules of [ARBITRATION ADMINISTRATOR]. The arbitrator shall have authority to grant all remedies available in court, except punitive damages to the extent prohibited by law.
8.3 Jury Trial. Each party acknowledges its constitutional right to a jury trial and agrees that selection of arbitration under Section 3.3 constitutes a voluntary waiver of that right for the specific dispute.
8.4 Injunctive Relief. A party may seek temporary or preliminary injunctive relief solely to enforce confidentiality or intellectual-property rights, subject to Section 6.4.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver. No amendment or waiver is effective unless in a signed writing referring to this Consent Form.
9.2 Assignment. Neither party may assign its rights or obligations without the other party’s prior written consent, except that Provider may assign receivables to a billing service.
9.3 Successors & Assigns. This Consent Form binds and benefits the parties and their lawful successors and permitted assigns.
9.4 Severability. If any provision is held unenforceable, it shall be construed to give maximum lawful effect, and the remainder shall continue in full force.
9.5 Integration. This Consent Form, together with all incorporated Disclosure Materials, constitutes the entire agreement regarding the Treatment and supersedes all prior oral or written statements.
9.6 Counterparts; Electronic Signatures. This Consent Form may be executed in counterparts, each deemed an original. Signatures transmitted via electronic means satisfy any legal requirement for an original signature under Wash. Rev. Code Ann. § 19.360.020 (Uniform Electronic Transactions Act).
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Consent Form effective as of the Effective Date.
| Patient | Health Care Provider |
| ______ | ________ |
| [PATIENT NAME] | [AUTHORIZED CLINICIAN NAME & TITLE] |
| Date: ______ | Date: ________ |
If Patient lacks Capacity:
| Authorized Representative | Relationship to Patient |
| ______ | ________ |
| Date: ______ |
Optional Witness (recommended for high-risk procedures):
| Witness Name: ____ | Signature: ____ |
| Date: ______ | |
[Seal/Notary Acknowledgment, if required]
[// GUIDANCE: Retain this executed document and Disclosure Materials in the patient’s medical record for a period not less than eight (8) years, or longer if required by Wash. Admin. Code § 246-08-400 or Medicare Conditions of Participation.]