Medical Legal Forms

Posted by Nurse Linda in Daily Dose on November 14, 2022 # Health

documentThere are many medical-legal forms available that can help guide your health care. All the details of these many forms should be discussed with your healthcare professional, legal advisor, family, caregivers, and anyone else you feel is appropriate. This is an overview of just a few of the many medical-legal forms. Remember, once you have decided on the medical care you wish to receive, your decisions can be changed at any time.

Consent to Treat Form: When you go to your healthcare provider’s office, the hospital, laboratory, therapy, or any other healthcare provider, you are always asked to sign their consent to treat form. People usually sign without reading the form, which should never be done with a legal document. Often the receptionist will outline what is in the form for you, which is helpful but not complete. Legal documents should always be read carefully prior to signing to be sure you know just what you are authorizing.

Information in the consent-to-treat form is fairly standard, but various agencies use different terminology and may have additional or less information. Generally, these forms contain statements that you agree to the medical treatment provided by the staff at the organization where you are. This is fairly straightforward in that you are agreeing to the providers to review your medical records, talk with you about your health condition, examine your body, and provide the medical care that is suggested. It does not mean you have to accept their treatment decisions but after all, that is why you are there, to benefit from your healthcare provider’s expertise.

These forms also ask for your consent to bill your health insurance provider(s). A part of this consent is that your insurance provider can look at your medical record for billing purposes. The insurance payor will decide what part or all of your treatment will be paid based on your individual medical healthcare policy. The rest of the payment will be your responsibility. Your signature indicates you are in agreement with this payment arrangement. In other words, what your insurance does not pay, you will. If you do not have healthcare insurance, you are agreeing to pay the bill in full.

There is also information that says you can refuse any treatment or procedure offered. Just because a treatment is offered that is deemed by the healthcare professional to be beneficial for you, does not mean you have to do it. However, that is usually not the best course of action.

Permission to share information with other healthcare providers for the issue at hand is usually in the consent to treat document. That allows continuity of care for you. The information from this medical visit may be shared with home, health, the hospital, consultations, and others who may provide care for your issue.

An often-overlooked part of the consent to treat is that you can discuss your care with family members prior to agreeing to implement and follow the treatment plan.

Individual offices or facilities may have additional information within the consent-to-treat form. Reading the entire form will let you know to what you are agreeing with your signature. As with legal documents, you can line out parts you disagree with, but if you do, you may be refused service. For instance, if you disagree with payment, you probably will not be seen in that clinic. Also, most people just sign, so requesting a paper copy that you can modify will lead to great confusion by the office staff as this would be such an unusual process. They may have to have their legal team review your modifications which would greatly increase your waiting time (by weeks or months) to be seen, and may reject you from services. Doing this is most unusual, but it is your right.

Advanced Directives

A group of documents called advanced directives includes a living will, durable power of attorney, physician orders for life-sustaining treatment, do not resuscitate orders, and organ and tissue donation. These documents can be completed singly or as a group of documents. There is also the option of altering them at a later date if your thoughts change.

States can have slightly different laws about these documents. If you want to look over sample documents, look under your state followed by the document such as “California Living Will’’. Looking at a sample will help you understand what is contained in the document. You can amend the documents as you would like and, if you choose, change, or discontinue them later.

Living Will: A living will includes your healthcare wishes should you be unable to tell a healthcare provider what you would like done for you medically. This helps take the burden off family members in decision-making as it ensures your wishes are carried out. The more specific you can be about your wishes, the better you will be served.

You must think through your living will carefully. For instance, many people do not want to be on life support, such as a ventilator. However, they do not think about needing a ventilator for short-term care. Eliminating ventilatory support can impede care for temporary pneumonia that you would survive.

Others request ‘Do Not Resuscitate’ when they do not want to have treatment if they stop breathing and their heart stops beating. However, they may not want chest compressions but do want cardiac medication. It is impossible to consider every healthcare crisis decision that can come up now or in the future as medical procedures improve and progress. For this reason, having a living will along with a power of attorney for medical issues is a good combination.

Organ/Tissue Donation: is another consideration that can be listed in your living will. You may want to donate certain parts of your body. States have registration systems to keep track of the tissues you want to donate. Your driver’s license also has a spot for which tissues you want to donate. Letting your family and physician know is also a way to contribute. The safest way to ensure your wishes about organ and tissue donation is through a state registry. Otherwise, there could be conflict at the time of need.

A Physician Orders for Life-Sustaining Treatment (POLST) is a set of orders created by your healthcare provider (physician or nurse practitioner). This document takes information from your living will and creates an order set for what care can be provided to you. This is posted in your room, so anyone providing care will know what to do should an issue occur.

Durable Power of Attorney for Healthcare or Medical Power of Attorney, Power of Attorney are similar documents with some differences. The durable power of attorney for healthcare or medical power of attorney gives the decision-making responsibility for healthcare issues to your selected appointee (this person is called your ‘agent’ in the legal world) only if you are unable to make decisions yourself. If you are capable of making your own decisions, your appointee cannot overrule them. A durable power of attorney can be used for healthcare decisions and financial decisions. You can appoint one person as your agent for both or separate individuals for medical and finances. The power of attorney is an agent who can act on your behalf if you are incapacitated temporarily or continuously.

There are all types of specifics as to what your agent can do and for how long they can act on your behalf. You may want them just to be responsible if you are incapacitated or full time depending on your situation. These documents can be dissolved at any time, or your agent can change them if you wish. If you elect to make a change, you may have to demonstrate your competency to make the decision. The person you choose should have your interests in mind as well as act on decisions that you would make as opposed to what they want. Having a frank discussion with your agent to ensure you have an understanding is essential.

There are many examples of living wills and medical power of attorney documents. Here are some sample sites:

There are many templates online for these documents. You can complete the forms and sign them but make sure they are legal in your state. Attorneys are very experienced in creating these documents. Their advice is beneficial to you to make sure all aspects of your wishes are covered as well as to be sure they are legal in your state. Different states have recommendations as to how to file them. You should keep a copy and provide a copy to your healthcare provider as well as to hospital personnel so it can be entered into your electronic medical record. If you amend or change your advance directives, you need to check to ensure the correct document is in your file.

Pediatric Consideration:

All parents of children should have emergency forms for healthcare, should you be away from your child. If your child will be in the care of another individual such as with grandparents, other relatives, caregivers, at school, or other places where you are not present, a consent to treat form should be pre-prepared. This allows the adult that is caring for the child to be able to authorize emergency medical treatment if needed. These forms include medical history, allergies, medication, as well as any special healthcare instructions. Samples of these forms can be found on the website of the American College of Emergency Physicians. Of course, you should have a plan to be reachable by phone. The use of this form will expedite treatment for your child. You will still need to sign the consent to treatment form by the medical organization where your child is being treated so insurance can be billed.

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.