Consent for Treatment

A member has the right to refuse any recommended medical procedure and to have sufficient information to make consent informed and meaningful. A legal guardian must make all medical decisions on behalf of a member who is not competent to make his or her own decisions.

If the physician or a court of competent jurisdiction determines that a member requires a representative other than a legal guardian to make medical decisions, that representative must be one of the following (in the order stated):

• Person designated under a Durable Power of Attorney for Health Care (DPAHC)
• Conservator specifically authorized by a court to make health care decisions
• Next of kin
• Any other surrogate designated consistent with applicable laws
• A person appointed by a court or, if the member is a minor, someone lawfully authorized to represent the minor

Physicians are responsible for providing members with sufficient information in lay terms, so that they can make informed decisions. All information must be disclosed that allows a reasonable person in the member's position to accept or reject a recommended procedure.

When to Use a Consent Form

Simple and common procedures, such as blood tests or urinalysis, do not require use of a consent form (except when required by law, such as for sensitive services). Consent does not need to be obtained if an emergency exists.

A consent form is used in conjunction with a thorough discussion with the member in order to obtain informed consent for any surgical, special diagnostic or special therapeutic procedure or when there is a statutory requirement. Any member requiring translation services must receive the form. Physicians must document in the member's medical record that the oral discussion leading to consent took place. Informed consent must be obtained in writing and must be signed by the member or legal representative. Consent forms must include:

• Member's name
• Physician's name
• Name of the procedure to be performed
• Authorization for a specified physician and assistants to perform a specified procedure
• Written explanation of the nature of the procedure, expected benefits of the procedure, expected discomfort, complications, or risks to the member, description of any alternative methods of treatment, and description of what will likely happen if the procedure is not performed
• Member's signature or legal representative's signature along with a copy of the legal document granting legal representation. A relative's signature, in the case of a documented existing medical emergency, does not need a court order
• Date and time
• Witness' signature

Providers with questions about legal consent should seek legal counsel. This explanation does not supplant advice of counsel.