Patient Consent Form - Treatment

DISCLAIMER (MANDATORY – DO NOT DELETE)
The following document is a model template for educational purposes only and does not constitute legal or medical advice. Use of this template does not create an attorney-client or physician-patient relationship. Wyoming and federal requirements governing informed consent are complex and frequently updated; a Wyoming-licensed attorney and the treating clinician must review, customize, and approve this form before implementation.

PATIENT CONSENT TO TREATMENT AGREEMENT

(Wyoming – Comprehensive Informed Consent Form)

Effective Date: [DATE]
Provider Entity: [LEGAL NAME OF HOSPITAL/CLINIC/PHYSICIAN GROUP] ("Provider")
Treating Clinician: [NAME & WY MEDICAL LICENSE NO.]
Patient: [LEGAL NAME] ("Patient")
Authorized Representative (if any): [NAME & RELATIONSHIP] ("Representative")
Jurisdiction/Governing Law: State of Wyoming ("WY")

TABLE OF CONTENTS

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

I. DOCUMENT HEADER

A. Purpose. This Agreement records the informed consent of Patient (or Representative) for the performance of one or more medical treatments, procedures, or services (collectively, "Treatment") by Provider, in compliance with applicable Wyoming informed-consent standards as articulated in Roybal v. Bell, 778 P.2d 108 (Wyo. 1989), and the Wyoming Health Care Decisions Act, Wyo. Stat. Ann. § 35-22-401 et seq.

B. Consideration. In consideration of Provider's agreement to furnish Treatment and related services, and other good and valuable consideration, the sufficiency of which the Parties acknowledge, the Parties agree as set forth herein.

C. Acknowledgment of Receipt. Patient acknowledges receipt of a copy of this Agreement and that the provisions have been explained in language Patient understands.

II. DEFINITIONS

"Adverse Event" – Any unanticipated injury or complication arising in connection with Treatment that may require further medical intervention.

"Capacity" – The ability to understand the nature, risks, benefits, and alternatives of Treatment and to make and communicate a decision, consistent with Wyo. Stat. Ann. § 35-22-402(a)(iii) (definition of "capacity" under the Wyoming Health Care Decisions Act).

"Confidential Information" – Individually identifiable health information subject to the federal Health Insurance Portability and Accountability Act (HIPAA) and applicable Wyoming confidentiality law.

"Emergency Condition" – A condition in which delay in Treatment would jeopardize Patient's life, health, or bodily function, in which event consent is implied at law and Provider may proceed under Wyo. Stat. Ann. § 35-22-408 and common-law emergency doctrine.

"Informed Consent" – Voluntary authorization given by Patient or Representative after the disclosures required under the Roybal standard (i.e., disclosure of risks that a reasonable practitioner of like training would disclose under similar circumstances), including: (i) diagnosis; (ii) proposed Treatment; (iii) material risks and expected benefits; (iv) reasonable alternatives (including the option of no treatment); and (v) answers to Patient's questions.

"Parties" – Collectively, Provider, Patient, and Representative (if any).

"Protected Health Information (PHI)" – As defined in 45 C.F.R. § 160.103.

"Surrogate" – A person authorized to make health care decisions for Patient under Wyo. Stat. Ann. § 35-22-406, in the order of priority listed in that statute.

III. OPERATIVE PROVISIONS

3.1 Description of Treatment.
a. Nature of Treatment: [DETAILED DESCRIPTION].
b. Expected Benefits: [DESCRIPTION].
c. Material Risks & Complications: [List OR attach Schedule 1].
d. Reasonable Alternatives: [List, including option of no treatment].
e. Consequences of Declining/Delaying Treatment: [List].

3.2 Disclosure Standard. Provider has disclosed, and Patient acknowledges receipt of, information sufficient to satisfy the Wyoming "reasonable practitioner" disclosure standard articulated in Roybal v. Bell, 778 P.2d 108 (Wyo. 1989) (physicians must disclose the risks that a reasonable practitioner of like training would disclose under similar circumstances).

3.3 Voluntary Consent. Patient confirms that consent is given voluntarily and may be withdrawn at any time prior to performance of Treatment, subject to Section 6 (Default & Remedies).

3.4 Right to Questions. Patient was encouraged to ask questions, and all questions were answered to Patient's satisfaction.

3.5 Financial Responsibility. Patient agrees to be financially responsible for charges associated with Treatment not covered by insurance. [PLACEHOLDER – insert detailed billing policy].

3.6 Confidentiality & Privacy. Provider will use Confidential Information solely for Treatment, payment, and healthcare operations consistent with HIPAA and applicable Wyoming law. Patient consents to such use and acknowledges receipt of Provider's Notice of Privacy Practices.

3.7 Capacity & Surrogate Decision-Making.
a. Capacity Verification. Provider has verified Patient's Capacity, or, if lacking, has obtained consent from a Representative or Surrogate in compliance with Wyo. Stat. Ann. §§ 35-22-403 (advance health care directives), 35-22-406 (decisions by surrogate), or 35-22-407 (decisions by guardian).
b. Advance Directive. Patient [☐ has] [☐ has not] executed an advance health care directive under the Wyoming Health Care Decisions Act. If yes, a copy is attached as Schedule 3.

3.8 Minor Consent. The Wyoming age of majority is eighteen (18) (Wyo. Stat. Ann. § 14-1-101(a)). Treatment of a minor requires consent of a parent or legal guardian unless one of the following applies:
☐ Patient is an emancipated minor (married, in U.S. military service, or judicially emancipated under Wyo. Stat. Ann. §§ 14-1-201 through 14-1-206).
☐ Patient is living apart from parents/guardian and managing own affairs (Wyo. Stat. Ann. § 14-1-101(b)).
☐ Patient's parent/guardian cannot be located with reasonable diligence and the need for treatment is sufficiently urgent.
☐ Treatment relates to a sexually transmitted disease (Wyo. Stat. Ann. § 35-4-131).
☐ Treatment relates to substance abuse (Wyo. Stat. Ann. § 14-2-310 / applicable substance abuse statute).
☐ Patient is 12 or older and Treatment is a tobacco cessation program (Wyo. Stat. Ann. § 14-1-101).

3.9 Emergency Treatment Exception. In an Emergency Condition where informed consent cannot practicably be obtained, Provider may proceed under applicable emergency exceptions.

IV. REPRESENTATIONS & WARRANTIES

4.1 Patient/Representative Representations.
a. Authority & Identity. Representative warrants legal authority to act for Patient (e.g., as agent under advance directive, surrogate, guardian, or parent of minor).
b. Accuracy of Information. All information furnished is true, complete, and accurate.
c. Understanding. Patient/Representative represents understanding of this Agreement.

4.2 Provider Representations.
a. Licensure & Qualifications. Provider and Treating Clinician are duly licensed in Wyoming under the Wyoming Medical Practice Act, Wyo. Stat. Ann. § 33-26-101 et seq.
b. Standard of Care. Treatment will be rendered consistent with prevailing professional standards in the relevant medical community.
c. Disclosure Compliance. Provider has made disclosures sufficient for Informed Consent under the Roybal standard.

4.3 Survival. Sections 4.1–4.2 survive completion or termination of Treatment.

V. COVENANTS & RESTRICTIONS

5.1 Patient Covenants.
a. Cooperation with pre- and post-Treatment instructions.
b. Prompt notification of any Adverse Event or change in condition.

5.2 Provider Covenants.
a. Recordkeeping consistent with applicable Wyoming Board of Medicine rules and HIPAA.
b. Maintenance of professional liability insurance in commercially reasonable amounts.

VI. DEFAULT & REMEDIES

6.1 Events of Default.
a. Non-Payment by Patient.
b. Material Misrepresentation by any Party.
c. Withdrawal of consent during an ongoing procedure in a manner that creates an Emergency Condition.

6.2 Notice & Cure. The non-defaulting Party must provide written notice specifying the default. The defaulting Party shall have ten (10) calendar days to cure a monetary default and a reasonable period not to exceed fifteen (15) calendar days to cure any non-monetary default.

6.3 Remedies. Suspension or termination of non-emergency Treatment, recovery of reasonable collection costs, and any other remedy available at law or equity, subject to Section 7.

VII. RISK ALLOCATION

7.1 Indemnification. Patient agrees to indemnify Provider for claims arising from Patient's breach of this Agreement or failure to follow medical instructions, except to the extent caused by Provider's negligence or willful misconduct.

7.2 Limitation of Liability. Nothing in this Agreement limits Provider's liability for professional negligence. Wyoming does not impose a statutory cap on non-economic damages in medical malpractice actions; the Wyoming Constitution Art. 10, § 4 prohibits any law limiting recovery for personal injury or death.

7.3 Force Majeure. Provider shall not be liable for delay or failure to perform due to events beyond its reasonable control.

VIII. DISPUTE RESOLUTION

8.1 Governing Law. This Agreement is governed by the laws of the State of Wyoming, without regard to conflict-of-laws principles.

8.2 Forum Selection. Exclusive venue shall lie in the Wyoming district court for the county in which Treatment is rendered, except as provided in Section 8.3.

8.3 Optional Arbitration. [SELECT ONE]
☐ Patient elects binding arbitration pursuant to the Wyoming Uniform Arbitration Act, Wyo. Stat. Ann. § 1-36-101 et seq. The arbitration shall be administered by [AAA / JAMS / OTHER] under its health-care rules.
☐ Patient declines arbitration; disputes will be resolved in court.

8.4 Jury Trial. If arbitration is not elected, the Parties acknowledge the constitutional right to a jury trial under Wyo. Const. art. 1, § 9, and do not waive that right herein.

8.5 Injunctive Relief. Either Party may seek limited injunctive relief only to protect PHI or to enforce non-disclosure obligations.

IX. GENERAL PROVISIONS

9.1 Amendments & Waivers. Any amendment or waiver must be in a signed writing.

9.2 Assignment. Patient may not assign rights or delegate duties without Provider's prior written consent.

9.3 Severability. If any provision is held invalid, the remaining provisions shall remain enforceable.

9.4 Integration. This Agreement, together with any schedules and Provider's Notice of Privacy Practices, constitutes the entire agreement regarding the subject matter.

9.5 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts (including electronic signatures under the Wyoming Uniform Electronic Transactions Act, Wyo. Stat. Ann. § 40-21-101 et seq.).

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.

A. Patient / Representative

B. Provider

SCHEDULE 1 – DISCLOSURE OF MATERIAL RISKS & ALTERNATIVES

[Use plain language understandable to Patient; tailor to each specific procedure consistent with the Roybal v. Bell reasonable-practitioner standard.]

SCHEDULE 2 – NOTICE OF PRIVACY PRACTICES

[Attach most recent HIPAA-compliant notice or incorporate by reference.]

SCHEDULE 3 – ADVANCE HEALTH CARE DIRECTIVE (IF APPLICABLE)

[Attach copy of any directive executed under Wyo. Stat. Ann. § 35-22-401 et seq.]

SOURCES AND REFERENCES

• Wyoming Health Care Decisions Act, Wyo. Stat. Ann. § 35-22-401 et seq.
• Wyoming Living Will Act, Wyo. Stat. Ann. § 35-22-101 et seq.
• Wyoming Medical Practice Act, Wyo. Stat. Ann. § 33-26-101 et seq.
• Wyo. Stat. Ann. § 14-1-101 (age of majority and minor consent exceptions)
• Wyo. Stat. Ann. § 35-4-131 (minor consent for STD treatment)
• Roybal v. Bell, 778 P.2d 108 (Wyo. 1989) (informed-consent standard)
• Wyo. Const. art. 10, § 4 (no cap on personal injury damages)