Navigating Legal Consent Language in Private Practices – Sample Consent Language!
Navigating Legal Consent Language in Private Practices - Sample Consent Language!

In the realm of healthcare, clear communication is paramount—not just in interactions with patients but also in the documentation that accompanies these interactions. Legal consent language is a critical component of this documentation, ensuring that patients are fully aware of and agree to the procedures and treatments they are about to undergo. This blog post explores what medical consent language is, why it is so important, and how practitioners in private practices can implement it effectively.

Understanding Medical Consent Language

Medical consent language forms the foundation of the informed consent process in healthcare. It involves providing a patient with information regarding their medical condition, the proposed interventions, and any potential risks and benefits, enabling them to make an informed decision about their care.

The consent language must be clear and comprehensive, explaining in understandable terms what the patient should expect during treatment. This includes details about the procedure itself, any potential risks, the expected outcomes, and any alternatives that may be available, including the option of not proceeding with any treatment.

For practitioners, crafting medical consent language is not just a legal requirement but a moral one as well. It respects the patient’s right to autonomy and self-determination regarding their own body and medical treatment. The language used should avoid medical jargon as much as possible to ensure that patients with non-medical backgrounds can understand the information provided.

Moreover, the format of the consent should be structured in a way that prompts discussion between the patient and provider. This is not just a formality but a crucial part of the patient care process, ensuring that all parties are on the same page and that the patient feels valued and understood.


The Importance of Medical Consent Language

The significance of medical consent language extends beyond mere legal compliance. It is a crucial element of ethical medical practice. By ensuring that consent language is clear and thorough, healthcare providers uphold the ethical standards of beneficence, non-maleficence, autonomy, and justice.

From a legal standpoint, proper consent language protects both the patient and the healthcare provider. It minimizes the risk of misunderstandings and the potential for legal disputes by clarifying what has been agreed upon between the patient and the practitioner. This is particularly important in today’s litigious society, where disputes over consent can lead to protracted legal battles.

Ethically, it fosters trust and strengthens the therapeutic alliance between the patient and the healthcare provider. When patients understand what is involved in their care and have had the opportunity to ask questions and express concerns, they are more likely to feel in control of their healthcare decisions and satisfied with the care they receive.

Furthermore, well-executed consent is integral to patient-centered care, which emphasizes the patient’s role in their own healthcare journey. It ensures that patients are not merely passive recipients of care but are active, informed participants in their treatment planning and execution.

Implementing Effective Consent Language in Private Practices

Implementing effective medical consent language requires more than just understanding its importance—it necessitates a proactive approach to ensure that all legal and ethical standards are consistently met.

First, private practices should develop standard consent templates that can be customized for different procedures and treatments. These templates should be reviewed and updated regularly to reflect current laws and ethical guidelines, as well as any advancements in medical treatment and technology.

Training is another critical component. All healthcare providers, including doctors, nurses, and administrative staff, should be trained in the principles of informed consent and the specific consent processes of their practice. This includes understanding how to communicate effectively with patients about consent and how to handle special situations, such as obtaining consent from minors or individuals with impaired decision-making capacity.

Additionally, private practices should utilize technology to streamline the consent process. Digital consent forms, for example, can be used to ensure that standardized, up-to-date consent language is used consistently across the practice. They also offer the convenience of easy storage and retrieval, which is essential for maintaining accurate records in case of audits or legal inquiries.


Incorporating effective medical consent language into the practice environment is a key responsibility of healthcare providers. By focusing on clarity, compliance, and patient engagement, private practices can not only fulfill their legal and ethical obligations but also enhance the overall patient experience, building a foundation of trust and respect that is beneficial to all involved.




Sample Private Practice Consent Language

Important Note:  Please be aware that the sample consent language provided herein is for illustrative purposes only and does not constitute legal advice. It is crucial for you to consult with legal counsel to review and tailor your practice’s consent language. This ensures that it fully complies with the specific legal requirements and regulations applicable to your operation and location.

Informed Consent

I, the client (or parent/legal guardian), understand that I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement. It does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with the clinician before I begin formal treatment. If at any time during my treatment I have questions about any of the subjects discussed in this brochure, I can talk with my clinician about them. Signing indicates that you understand and agree that you will participate in the planning of your care, treatment, or services, and that you may stop such care, treatment, or services at any time. By signing this policy, you acknowledge that you have both read and understood all the terms and information contained herein. Ample opportunity has been offered for you to ask questions and seek clarification of anything that remains unclear. I have chosen to receive mental health services for myself and/or my child from The Provider. My decision is voluntary, and I understand that I may terminate these services at any time, unless my participation has been mandated by a court of law.

HIPAA Notice of Privacy Practices

  1. Purpose This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The Provider, employees, and trainees follow the privacy practices described in this Notice. The Provider keeps your mental health information in records that will be maintained and protected in a confidential manner, as required by law. Please note that to provide you with the best possible care and treatment, all professional staff involved in your treatment and employees involved in the health care operations of The Provider may have access to your records. 
  2. What are treatment, payment, and health care operations? Your treatment includes sharing information among mental health care providers who are involved in your treatment. For example, if you are seeing both a physician (psychiatrist) and a psychotherapist, they may share information in the process of coordinating your care. Information will not be shared with other providers without a signed exchange of information form. We may use and disclose your medical information to bill and collect payment for treatment and services provided to you. Treatment records may be reviewed as part of an on-going process directed toward assuring the quality of This Provider operations. 
  3. How will This Provider use my protected health information? Your personal mental health record will be retained by The Provider for approximately seven years after your last clinical contact with the agency. After that time has elapsed, the record will be destroyed or otherwise maintained in a way that protects your privacy. Until the records are destroyed, they may be used, unless you ask for restrictions on a specific use or disclosure, for the following purposes: 
    1. Appointment reminders 
    2. Notification when an appointment is cancelled or rescheduled 
    3. Treatment alternatives 
    4. Research 
      1. We may release information about you to researchers preparing to conduct a research project who need to know how many patients have a specific health problem. 
      2. We may use and disclose medical information about you for research purposes if the research has been subjected to a careful review process conducted by a specially selected and trained committee and received this committee’s approval. This process evaluates a proposed research project and its use of medical information and balances the potential benefit of the research against individual patients’ needs for privacy of their medical information. 
      3. A research project may involve comparing the health and recovery of all patients who received one treatment to those who received another for the same condition. In that situation, you would not be identified or contacted, but your medical information may be used but kept confidential. 
      4. In other studies, if a provider caring for you believes you may be interested in, or benefit from, a research study, The Provider and the committee will approve someone to contact you to see if you are interested in the study. At that time, you would receive more information and you would have the right to authorize continued contact or refuse further contact. 
    5. Workers’ Compensation – We may release medical information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illness. 
    6. As may be required by law
    7. For public health purposes such as reporting of child or elder abuse or neglect; reporting reactions to medications; infectious disease control; notifying authorities of suspected abuse, neglect, or domestic violence (if you agree or as required by law) 
    8. Mental health oversight activities, e.g., audits, inspections or investigations of administration and management of The Provider. 
    9. Individuals involved in your care or payment for your care. We may release medical information about you to a friend or family member who is involved in your therapeutic care. In addition, we may disclose medical information about you to another entity assisting in disaster relief efforts so that your family can be notified about your condition, status, and location. If you do not want this information shared, please let us know in writing. 
    10. Lawsuits and disputes (We will attempt to provide you advance notice of subpoena before disclosing information from your record)
    11. Law enforcement (e.g., in response to a court order or other legal process) to identify or locate an individual being sought by authorities; about victim of a crime under restricted circumstances; about a death that may be the result of criminal conduct; about criminal conduct that occurred in The Provider facilities, when emergency circumstances occur relating to a crime. 
    12. To prevent a serious threat to health or safety 
    13. To carry out treatment and health care operations functions through medical transcription services 
    14. To military command authorities if you are a member of the armed forces or a member of a foreign military authority
    15. National security and intelligence activities o Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations
    16. Alcohol and drug abuse information has special privacy protections. The Provider will not disclose any information identifying an individual as being a client or provide any mental health or medical information relating to a client¹s substance abuse treatment unless: (1) the client consents in writing; (2) a court order requires disclosure of the information; (3) medical personnel need the information to meet a medical emergency; (4) qualified personnel use the information for the purpose of conducting research, management audits, or program evaluation; or (5) it is necessary to report a crime or a threat to commit a crime or to report abuse or neglect as required by law. 
  4. Your authorization is required for other disclosures. Except as described previously, we will not use or disclose information from your record unless you authorize (permit) in writing The Provider to do so. You may revoke your permission in writing, which will be effective only after the date of your written revocation. 
  5. You have rights regarding your protected health information. You have the following rights regarding your health information if you make a written request to invoke the right to The Provider. 
    1. Right to request restriction. You may request limitations on your mental health information we may disclose, but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment. 
    2. Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify in writing how or where you wish to be contacted.
    3. Right to inspect and copy. You have the right to inspect and copy your mental health information regarding decisions about your care; however, psychotherapy notes may not be inspected and copied. We may charge a fee for copying, mailing, and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed mental health professional chosen by The Provider. The Provider will comply with the outcome of the review. 
    4. Right to request record clarification. If you believe that the information, we have about you is incorrect or incomplete you may ask to add clarifying information. The Provider is not required to accept the information that you propose. 
    5. Right to accounting of disclosures. You may request a list of the disclosures of your mental health information that have been made to persons or entities other than for treatment or health care operations in the last six (6) years, but not prior to April 14, 2003.
    6. Right to a copy of this Notice. You may request a copy of this Notice at any time, even if you have been provided a copy. 
  6. Requirements regarding this notice. The Provider is required to provide you with this notice that governs our privacy practices. The Provider may change its policies or procedures regarding privacy practices. When changes occur, the changes will be effective for mental health information we have about you as well as any information we receive in the future. Any time you come into The Provider facilities for an appointment, Complaints. You may file a written complaint with The Provider if you believe your privacy rights have been violated. You will not be penalized or retaliated against in any way for making a complaint.


Consent to (Authorization for) Electronic Communications

At our first session, we will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, The Provider has the following policies regarding communications: 

  1. The best way to contact The Provider between sessions is to call by telephone at ____________ or secure text ______________.
  2. The Provider will make every effort to respond to your messages within 24 hours. Please note that The Provider may not respond at all on weekends or holidays. The Provider may also respond sooner than stated in this policy. That does not mean they will always respond that quickly. 

Our work is done primarily during our appointed sessions, which will generally occur during our business hours. Contact between sessions should be limited to: Confirming or changing appointment times and Billing questions or issues. Please note that all textual messages you exchange with The Provider, i.e., emails and text messages, will become a part of your health record.

The Provider may coordinate care with one or more of your other providers. The Provider will use reasonable care to ensure that those communications are secure and that they safeguard your privacy. 

Our Safety and Emergency Plan

As a recipient of telehealth-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with The Provider.  The Provider will require you to designate an emergency contact. You will need to provide permission for The Provider to communicate with this person about your care during emergencies. The Provider will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions. It is important that you engage with The Provider in the creation of these plans and that you follow them when you need to. Telehealth with The Provider is not an Emergency Service and in the event of an emergency, you are to use a phone to call 911. 

Your Security and Privacy

Except where otherwise noted, The Provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged. Please refer to the Electronic Records Disclosure section of this document for a complete description of how your privacy is maintained by The Provider.

As with all things in telehealth, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with The Provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that The Provider has supplied for communications. To maintain confidentiality, do not share your telehealth appointment link with anyone unauthorized to attend the appointment. 


Please do not record video or audio sessions without The Provider’s consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. The Provider will not record video or audio sessions.


Consent to (Authorization for) & Electronic Records

  1. Provider keeps and stores records for each client in a record-keeping system produced and maintained by Embark EMR. This system is “cloud-based,” meaning the records are stored on servers which are connected to the Internet. Here are the ways in which the security of these records is maintained: 
    1. The Provider has entered into a HIPAA Business Associate Agreement with Embark EMR. Because of this agreement, Embark EMR is obligated by federal law to protect these records from unauthorized use or disclosure.
    2. The computers on which these records are stored are kept in secure data centers, where various physical security measures are used to maintain the protection of the computers from physical access by unauthorized persons. 
    3. Embark EMR employs various technical security measures to maintain the protection of these records from unauthorized use or disclosure. 
    4. Customer data that is uploaded or created in Embark EMR services is encrypted at rest. Embark EMR enables HTTPS for all its services, so that data is encrypted when traveling from my device to Embark EMR and while in transit between Embark EMR data centers.
  2. The Provider has their own security measures for protecting the devices that we use to access these records: 
    1. On computers, The Provider employs firewalls, antivirus software, passwords, and disk encryption to protect the computer from unauthorized access and thus to protect the records from unauthorized access. 
    2. With mobile devices, The Provider uses passwords, remote tracking, and remote wipe to maintain the security of the device and prevent unauthorized persons from using it to access my records. 
    3. Electronic client records maintained on secured and encrypted computer hard drive.
    4. Client database is encrypted and password-protected 
    5. Laptop computer uses anti-virus software to prevent unauthorized access and maintain healthy 
  3. The Provider keeps and stores records for each client electronically, using the following resources: 
    1. Client data, notes and scheduling software is a cloud-based system with database storage located in a HIPAA compliant and secured Amazon Web Services Cloud Environment. Database is password-protected with multi-factor authentication and is encrypted. 
    2. Laptop computer in a secured office building and/or secured residence. 
  4. Here are the ways in which the security of those records is maintained:
    1. On computers, we employ firewalls, antivirus software, passwords, and disk encryption to protect the computer from unauthorized access and thus to protect the records from unauthorized access. 
    2. To help prevent the loss or damage of records, we keep backups of them using an online backup service (“cloud based”) produced and maintained by Embark EMR. 
    3. We have entered into a HIPAA Business Associate Agreement with Embark EMR. The details of which are outlined above. 
    4. Other security measures as stated above.
  5. Here are things to keep in mind about The Provider record-keeping system: 
    1. While Embark EMR and The Provider both use security measures to protect these records, their security cannot be guaranteed. 
    2. The Provider does not utilize third party client data, notes and scheduling software and therefore maintains all of its own records. We use the above-mentioned security measures to protect these records, however their security cannot be guaranteed.
    3. Some workforce members and contract employees at The Provider such as engineers or administrators, may have the ability to access these records for the purpose of maintaining the system itself. The Provider is obligated by law to train our staff on the proper maintenance of confidential records and to prevent misuse or unauthorized disclosure of these records. This protection cannot be guaranteed, however. 
    4. The Provider maintains a log of client transactions for various purposes, including maintaining the integrity of the records and allowing for security audits. These transactions are kept for 7 years. 
  6. In addition to the protection of your electronic Personal Health Information as outlined above: 
    1. The Provider maintains hardcopies of certain records which are maintained at a secured office site under the standard double lock rule for a period of 7 years. 
    2. Email, Voice, and SMS Text communications are stored on secured and encrypted storage systems in offsite, cloud-based HIPAA-compliant systems through ________________.  _______________’s HIPAA-compliant solution ensures that customer calls and messages are secure with encryption in transit and at-rest, along with other features, protecting patient data and guarding against unauthorized access to protected health information. 
    3. Please note that all text and voice messages you exchange with The Provider, e.g. emails, voice mail messages, text messages and telephone conversations will become a part of your health record.


Consent to (Authorization for) Electronic Payment

Credit/HSA Card on File Agreement Policy 

  1. I, the undersigned, authorize The Provider to charge my credit card, indicated below, for services rendered and charges incurred at the rates agreed upon in the financial policy. This includes service charges relative to billing and missed appointments or cancellations with less than two business days’ notice. 
  2. I understand that my information will be saved to file for future transactions on my account. The Provider agrees to make every effort to keep all credit card information confidential and secure and to process payments to my card only after the agreed upon fee has been incurred. The Provider will only utilize this information when I am not physically able to present my card at the time of service. 
  3. This authorization will remain in effect until I cancel this authorization. I may cancel this authorization at any time by providing written notification to The Provider. Authorization will end within 30 days of receipt of said written notification.


Financial Policy

  1. All payments are due at the time of service. Payment will be accepted in the form of cash, check and most debit or credit cards. In most cases, credit/debit cards tied to your Health Savings Account (HSA), Health Reimbursement Account (HRA) of Flexible Spending Account (FSA) will also be accepted.
  2. Credit and Debit Cards: Visa, MasterCard, Discover, and American Express are accepted. You will be required to keep a card on file with this office agreeing to charges being processed as they occur (including late, cancel, administrative and no-show fees). If you would like to keep an HSA/HCA/FSA card on file for payment of therapy visits, you may do so. However, you will still be required to keep a credit/debit card on file for payment of all non-medically covered charges (i.e., reports, consults, fees, service charges, late or cancel fees etc.). It will be the responsibility of the financially responsible party to keep all credit card information up to date with this office. Any complications due to out-of-date information may be subject to a service charge 
  3. Checks and Cash: Personal checks and cash are accepted for visits that occur in office/in person. Postdated checks cannot be accepted. There will be a service charge for checks returned for insufficient funds each time a check is returned. 
  4. Out-of-Network Reimbursement: If you would like to seek reimbursement for out-of-network mental health services through your insurer or HSA/HRA/FSA, a detailed receipt will be provided at time of payment. Submission of these receipts in order for you to receive reimbursement from your insurer or HSA/HRA/FSA is your responsibility. Directions for doing so can be accessed by calling the member service line on the back of your insurance card. Indicate to the representative that you would like information on pursuing reimbursement for out-of-network benefits for out-patient mental health services provided in an office setting. During this call you will want to confirm with your representative your out-of-network benefits, what you will need to submit to receive reimbursement and how the envelope should be addressed. A password protected pdf of the detailed receipt (or “super bill”) will be e-mailed to the person you indicated in the intake paperwork after each visit. It is the responsibility of this person to confirm receipt of the statement and save the document in a safe and confidential way. Any requests for duplicate paperwork made after 7 days of the service date will incur a charge. You may opt out of receiving a receipt or request receiving receipts in an alternate manner (i.e. US postal service). In the case of the receipt being delivered via the USPS, requests after 30 days of the service date will incur a charge for duplicate paperwork. You may change your preference of if or how you receive a receipt at any time via written request. 
  5. Medicare/Medicaid/Tricare: The Provider is not a Medicare, Medicaid, or Tricare provider. Medicare, Medicaid, and Tricare will not reimburse you for any of your costs and do not provide out-of-network benefits. 
  6. Late Cancellation and Missed Appointments: As a show of grace, clients may miss an appointment or cancel less than two business days in advance one time without penalty. After which, any subsequently missed appointment or cancellation with less than two business days’ notice will be charged to the client’s account. It is understandable that some situations cannot be avoided, so if there is an emergency that requires you miss an appointment or cancel late, I’ll be happy to discuss this with you.
  7. Outstanding Balances: Any balance on your account past 30 days from the date of service will incur a late fee. Account balances remaining due after 120 days from the date of service will be referred to a collection agency. All collection fees incurred will also be your responsibility. If you have any questions or know that payment arrangements are necessary, please notify me as soon as possible. When it is necessary, I will do my best to work with you on financial matters.


Private Practice Policy

Privacy and Confidentiality:  Our private practice is committed to maintaining the confidentiality and privacy of your personal and health information. We adhere to all applicable laws and regulations to ensure the security of your data.

Communication:  We will strive to maintain open and effective communication with you throughout your engagement with our practice. You have the right to ask questions, seek clarification, and express your concerns at any time.

Fees and Payment:  Details regarding our fees, payment methods, and insurance billing practices can be found in our financial policies. Please review these policies for a comprehensive understanding of your financial responsibilities.


Permission to Screen Consent

Purpose of Screening:  I understand that as part of my engagement with [Practice Name], I may be asked to participate in screenings and assessments. These screenings are conducted to assess my mental and emotional well-being and to provide the best possible care.

Voluntary Participation:  I acknowledge that participation in screenings is voluntary, and I have the right to decline or discontinue any screening at any time without affecting my overall treatment.


Consent for Photo Release

Purpose of Photo Release:  I hereby grant permission for [Practice Name] to take photographs or videos of me for the purpose of clinical documentation, research, or educational materials related to my treatment.

Control and Usage:  I understand that [Practice Name] will exercise discretion and ensure that my identity is protected when using these photographs or videos. I have the right to revoke this consent at any time in writing.


Attendance Cancellation Policy

Cancellation Notice:  I acknowledge [Practice Name]’s attendance cancellation policy. I understand that I must provide at least [number of hours or days] notice to cancel or reschedule appointments. Failure to do so may result in charges for the missed appointment.

Exceptions:  Exceptions to this policy may be made in case of emergencies or extenuating circumstances, subject to [Practice Name]’s discretion.


Informed Consent

I have read, understood, and agreed to the policies and procedures outlined by [Practice Name]. I am aware that these policies are subject to change and that I will be informed of any revisions.


Telepractice Consent

Telehealth Services:  I understand that I may have the option to receive services through telehealth, including video and/or phone sessions. I acknowledge that the same standards of care and confidentiality apply to telehealth services.

Technical Requirements:  I am responsible for ensuring that I have access to the necessary technology and a secure internet connection to participate in telehealth sessions.


Start utilizing Embark EMR to enhance your practice

In conclusion, Embark EMR offers a comprehensive and affordable solution for managing patient records in your private practice. With our free 14-day trial, you can experience the simplicity and security of our system without any risk or commitment. Our pricing is unmatched in the industry, at only $20 per month per user with no additional fees. Plus, you can rest assured that your patients’ data is protected with our state-of-the-art security measures. Don’t hesitate any longer, start leveraging Embark EMR for your practice today and see the benefits for yourself!

Welcome to Embark EMR

An affordable and effective practice management solution, tailored for mental and physical health practitioners