Informed voluntary consent to medical intervention. Included in the list of certain types of medical interventions, on the Consent for surgical intervention form
From the point of view of the law, informed voluntary consent to the intervention is the official basis for the manipulations provided for by the medical programs of public and private institutions.
The article below contains information on when exactly it is necessary to write such a document, how to correctly compose it, and also how the staff of a medical organization will be punished for initiating assistance without an official permission signed by the “sick”.
Features of DIS
Informed voluntary consent to medical intervention is a unified, partially completed form that requires certification by the patient himself or his guardian (in the case of initiating treatment for a person under 18 years of age, a legally incompetent citizen).
When contacting a medical organization, they offer to fill out a voluntary informed consent for medical intervention.
According to the law, it must be provided for review, completion and signature immediately before medical procedures.
The consent in question is required to be filled out not only for the one-time provision of medical assistance to a person during the initial or subsequent admission within the walls of a medical institution, but also at the moment when health workers start a card in a budgetary clinic, private medical center, school or preschool institution.
In all cases, the purpose, procedure and potential consequences of the proposed medical manipulations should be explained to the patient.
Traditionally, writing a DIS involves the following types of assistance from medical staff:
- preventive assessments of the patient's health status by highly specialized specialists;
- routine vaccination;
- passing complex medical commissions;
- conducting ultrasound, magnetic resonance and computer research;
- first aid by medical staff under any circumstances (bruise, fracture, onset of labor, and so on).
When is a document required?
Informed consent to an intervention is required when initiating any medical service, which is a set of measures, including:
- examination and questioning of the patient in order to collect complaints and describe the history of the current disease;
- measurement of the parameters of the patient's body at the current moment;
- measurement of body temperature, as well as blood pressure;
- assessment of visual acuity and hearing of the patient;
- determination of the state of the nervous system;
- collection of analyzes, biomaterial and other similar manipulations for the diagnosis of diseases;
- electrocardiogram;
- electroencephalography;
- X-ray studies;
- computed tomography (CT);
- Magnetic resonance imaging;
- massage procedures;
- physiotherapy;
- the use of medicines, in accordance with the prescriptions of the attending physician.
In accordance with the law, any actions on the part of doctors aimed at the slightest change in the mental or physical state of the "patient" in any case require the issuance of permission from the patient himself, or his capable relatives.
Rules for filing a document
Informed voluntary consent to medical intervention is drawn up and certified by a person of legal age or his capable relative (when writing permission in a preschool and school institution, and so on).
For proper documentation, it is necessary to follow the established the algorithm for granting permission to initiate intervention by the medical staff:
- Carefully read the information provided by medical professionals on the specific services required by the patient in this case: the purpose of the measures taken; ways of their implementation; expected result; possible complications due to the unpredictability of the reaction of the human body to outside interference.
- Examine the form of the document, in the vast majority of cases provided already in printed form by the administrators of the medical institution or by the doctors themselves.
- Clarify the points that remained unclear after the "briefing".
- If possible, take the consent form home and study it in a comfortable environment.
- Personally enter a list of manipulations allowed for medical staff to address the patient himself or his ward, whose interests he represents.
- Certify the document with a personal signature, indicating the date and decoding (last name, first name, patronymic).
In addition, in the documentation being drawn up, it is advisable to make sure that the information is indicated (if it is not available, add it yourself) about:
- place of registration or actual place of residence;
- date of birth;
- passport;
- Name of the employee who took the consent from the patient;
- persons who, if necessary, are allowed to be informed about the current stage of the patient's recovery;
- information about the hospital (for planned hospitalization).
Also, the DIS must contain the personal signature of the employee's accepted application and the seal of the institution within which the patient provided this document.
Responsibility for Non-DIS Medical Intervention
Responsibility for the provision of medical intervention without the consent of the patient in the conditions of state budgetary institutions involves the involvement of the leadership and the doctor himself to administrative punishment in the form of a fine or temporary suspension of professional activity.
In a situation where what happened within the walls of a private organization, then in addition to the above consequences, the paid institution will be forced to bear responsibility under Article 14.8 of the Code of the Russian Federation on Administrative Violations.
In case of harm to human health as a result of medical activities that are not included in the list permitted by the patient himself or his guardian, the medical staff will be forced to fully compensate for the physical damage, in the amount required by the injured themselves. In such situations, the proof of the guilt of the medical staff in what happened is not appropriate.
Free form is allowed
Informed voluntary consent to medical intervention in a number of circumstances is acceptable for compilation in an arbitrary version. According to their circumstances, not wanting to fill out a unified document form, the patient or his parent (guardian) can independently print or write by hand permission for certain medical procedures.
However, even with a categorical refusal to use the standard application form, the resulting documentation should strictly comply with the requirements of the legislation related to the writing of the DIS.
Sample of filling out the form
A sample of the DIS form required to be filled out in budgetary and paid medical institutions, as well as by parents in school and kindergarten:
When signing the above form by an adult citizen, personal information should be indicated in all columns.
In the case of filling out the consent of the parent (guardian), the following rules must be observed:
- three columns of the form, located at the top of the form, are filled in by an authorized person;
- the option “to receive primary health care by a person whose legal representative I am” is emphasized;
- in the column below the indicated information about the medical institution, the data of the minor person (last name, first name, patronymic and date of birth) are indicated;
- in the next free area, a place is allocated for the signature of the guardian;
- in the column "Date of issue" indicates the date of signing this consent.
Consent to certain types of medical procedures
In view of certain features of a separate series of manipulations by the medical staff, permission for them is issued each time immediately before they are carried out.
These most often include:
In this case, it is imperative before the intervention itself to make sure that the doctor has given a sufficiently detailed briefing about the potential dangers and side effects of the procedures being performed.
Equally important is the full name of the type of assistance from the medical staff, for which the permission is signed (as an option, when immunizing against measles, rubella and mumps in the form of a document, all three components of the vaccine must be prescribed without abbreviations and abbreviations).
Additional information on the form
The indication of third-party information in the standard form of the document in question is not provided. However, in the event of appropriate circumstances, the attending physician may create a separate box to indicate the notes associated with obtaining this consent, or the features of the potentially provided assistance to the human body.
It is worth emphasizing separately that the law does not prohibit the introduction of third-party notes into the unified DIS form.
Age at which a child is eligible for self-signing
On their own, a citizen over the age of 15 or prematurely recognized as capable has the right to issue a voluntary permit for the vast majority of types of assistance from the medical staff. However, there are also a number of exceptions that require the age of majority of a person to sign a unified form.
These unique circumstances include:
- donation in any of its manifestations;
- condition check provoked by suspicion of alcohol or drug intoxication;
- providing narcological assistance to drug addicts (the expediency of helping drug addicts, which is of a non-drug nature, is allowed to be determined for children from 16 years of age).
Document validity period
The period of validity of the document of the type in question is unlimited. In most situations, consent is filled out during the initial visit to a medical institution and is considered valid throughout the entire time of observation of a person by medical staff within its walls. However, this does not mean that the patient does not have the opportunity to subsequently change his mind and revoke the previously given consent.
To change the list of permitted medical manipulations, you must fill out the appropriate standard form or draw up an application yourself addressed to the administration of the medical organization. At the same time, a citizen is not obliged to indicate the reasons for such actions.
Actions in case of refusal of treatment
Refusal to provide assistance by medical staff, as well as permission for it, requires the patient to complete documentation using a unified form of a medical institution or write it in any form. The application should be sent to the administration of the institution, while observing all the recommendations on the legislation related to the preparation of such documentation.
In such a case, the health worker should clearly explain to the citizen the possible negative consequences of his refusal of the offered assistance from the medical staff.
In circumstances where there is continued reluctance to undergo treatment, the patient should fill out an appropriate application in the same way as consent, indicating that he was instructed in advance about the potential consequences.
Partial refusal of the procedures specified in the consent
According to the law, the patient, as well as his parent (guardian), can also make a partial waiver of the types of interventions by the medical staff mentioned earlier in the permit. To this end, he will need to fill out a standard form or draw up a document on his own, writing in it the full name of the prohibited procedures without abbreviations and other abbreviations.
On this form, traditionally, a column is provided for additional information prescribed by the attending physician about the potential dangers of refusing the help offered to the patient by the medical staff in a particular case.
DIS (informed voluntary consent to intervention) in the functioning of the human body by medical personnel should drawn up taking into account the instructions contained in the relevant legislative acts.
Having studied the above article, a citizen, and in some cases, his parent (guardian) will not only understand why this document is important, but also learn how to correctly compose it, as well as make specific adjustments, with partial or complete refusal to provide medical care.
Video about informed voluntary consent to medical intervention
DIS features:
Informed voluntary consent to medical intervention I ________________________________________________________________ (last name, first name, patronymic - in full) ____________ year of birth, residing at: ___________ ┌────────────────────────────────────────────────────────────────┐ │This section of the form is filled out only for persons who have not reached │ │ age 15, or disabled citizens: Me, passport: ______,│ │Issued by: _______________________________________________________________│ │I am a legal representative (mother, father, adoptive parent, │ │guardian, custodian) of a child or person recognized│ │incapacitated: ________________________________________________│ │ (Full name of a child or a disabled citizen -│ │ in full, year of birth) │ └────────────────────────────────────────────────────────────────┘ informed (delivered) that I (represented) hospitalized (hospitalized) in the department __________________________________________________________________ (indicate the name or profile of the department) - According to my will, I have been given full and comprehensive explanations about nature, severity and possible complications of my diseases (health of the person being represented); - I am familiarized (familiarized) with the schedule and rules medical and protective regime established in this medical institution, and I undertake to comply with them; - I voluntarily give my consent to conduct me (represented), in accordance with the doctor's prescriptions, diagnostic studies: blood analysis of general and biochemical, blood tests for the presence of the virus human immunodeficiency, viral hepatitis, treponema pallidum, general urine analysis, electrocardiography; holding x-ray, ultrasound and endoscopic examinations and therapeutic measures: taking tablets, injections, intravenous infusions, diagnostic and therapeutic punctures, physiotherapy procedures. The need for other methods examination and treatment will be explained to me further; - I am informed (informed) about the purposes, nature and adverse effects of diagnostic and therapeutic procedures, the possibility of unintentional harm to health, as well as about what I (represented) have to do during their holding; - I am notified (notified) that I (represented) need regularly take prescribed drugs and other treatments, immediately inform the doctor about any deterioration in well-being, coordinate with the doctor the intake of any non-prescribed medications; - I have been warned (warned) and I understand that refusing treatment, non-compliance with the medical and protective regimen, recommendations healthcare workers, drug regimen, unauthorized use of medical instruments and equipment, uncontrolled self-medication can complicate the treatment process and adversely affect health; - I informed the doctor about all the problems, related to health, including allergic manifestations or individual intolerance to drugs, about all the injuries I have suffered (represented) and known to me, operations, diseases, environmental and industrial physical, chemical or biological factors, affecting me (represented) during life, about the medications taken. I reported (reported) truthful information about heredity, as well as on the use of alcohol, narcotic and toxic drugs; - I ___________ agree (agree) to be examined by other medical employees and students of medical universities and colleges exclusively for medical, scientific or educational purposes, subject to maintaining medical confidentiality; - I have read (read) and agree (agree) with all paragraphs of this document, the provisions of which have been explained to me, I understand and voluntarily give my consent to the examination and treatment in the proposed volume; - I allow, if necessary, to provide information about my diagnosis, severity and nature of my disease my relatives, legal representatives, citizens: _______________ - I authorize a visit to the medical institution of the represented a child or a person recognized as incompetent, to the following citizens: _________________________________________________________________. ---- "__" ___________ 20__. Signature of the patient / legitimate |X | representative ---- Signed in my presence: ---- Doctor ___________________________________________ (signature) |X | (position, first and last name) ---- SEE THE BACK OF THE FORM NOTE: Consent to medical intervention (treatment) in relation to persons under the age of 15, and citizens recognized in legally incompetent, give them legal representatives (parents, adoptive parents, guardians or trustees) with indication of full name, passport data, family relations after providing them with information about the results of the survey, the presence disease, its diagnosis and prognosis, methods of treatment associated with their risk, possible options for medical intervention, their consequences and results of the treatment. In the absence of legal representatives, the decision on the need treatment is accepted by a council, and if it is impossible to convene a council - directly attending (duty) doctor with subsequent notification of the chief physician / head of the TsMSCH / MSCH / CB / Institute, and in weekends, holidays, evenings and nights - responsible doctor on duty and legal representatives.
There are cases when a medical organization has the right to carry out medical intervention without the consent of the patient. Such medical intervention is not a violation of the patient's right to his personal (physical) integrity and the right to prior information.
Medical intervention without IDS is carried out:
- according to emergency indications to eliminate the threat to a person’s life and if his condition does not allow him to express his will or there are no legal ones;
- in relation to persons suffering from diseases that pose a danger to others;
- in relation to persons suffering from severe mental disorders;
- in relation to persons who have committed socially dangerous acts (crimes);
- when conducting and (or) forensic psychiatric examination.
In other cases, the patient's refusal to issue an IDS may serve as a reason for the legal refusal of a medical organization to provide him with medical services. However, there are situations when it is expedient for a medical organization to provide a patient with medical care without issuing an IDS, rather than deny him it. We are talking about a situation where the patient categorically insists on a medical intervention, but refuses to sign the relevant documents. In such a situation, of course, it is necessary to draw up an act on the patient's refusal to issue an IDS, indicating the reasons for such refusal and indicating in the act that the patient himself insists on undergoing medical intervention. This is due to the fact that in the future it may turn out that the patient was not himself from pain, fear (other reasons) and could not understand the meaning of his actions and be guided by them, that from a simple wave of aggression against the bureaucratic element of medical care, he was not in able to be aware of their behavior. Each such situation should be assessed by a physician on an individual basis, and the decision to conduct medical intervention without an IDS should be made in a balanced and reasonable manner.
The order of medical intervention without the consent of the patient
| Cases of medical intervention without the consent of the patient | Who decides | Decision procedure |
|---|---|---|
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If the decision is made directly by the attending (duty) doctor, then the attending physician makes such a decision to the patient. Subsequently, the attending physician must notify the officials of the medical organization, the patient (his representative) about the medical intervention. |
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Court | The procedure for providing medical intervention is determined by the Criminal Code of the Russian Federation and the Code of Criminal Procedure of the Russian Federation, as well as Law of the Russian Federation of 02.07.1992 No. 3185-1"On psychiatric care and guarantees of the rights of citizens in its provision" |
| When conducting a forensic medical examination and (or) a forensic psychiatric examination | Court | The procedure for providing medical intervention is determined by the Code of Civil Procedure of the Russian Federation, the Code of Criminal Procedure of the Russian Federation, as well as the Federal Law of May 31, 2001 No. 73-FZ “On State Forensic Activities in the Russian Federation” |
for failure to fulfill the obligation to inform patients about medical services in accordance with the legislation of the Russian Federation, in particular for failure to issue consent forms or refusals of patients from medical interventions. Not issuing an IDS can be considered a violation (clause 5 a., c. Decrees of the Government of the Russian Federation of April 16, 2012 No. 291“On Licensing Medical Activities”), which will lead to an offensive in accordance with Parts 3, 4 of Art. 14.1 of the Code of Administrative Offenses of the Russian Federation.
Also, such a violation can be qualified simply as a violation of paragraph 28 Decree of the Government of the Russian Federation of 04.10.2012 No. 1006"On approval of the Rules for the provision of paid medical services by medical organizations", which will entail the onset of administrative responsibility in accordance with Art. 14.8 of the Code of Administrative Offenses of the Russian Federation.
A medical organization for not providing information, as well as providing false or insufficient information, may be held liable in accordance with the Civil Code of the Russian Federation and the Law of the Russian Federation of 07.02.1992 No. 2300-1 “On Protection of Consumer Rights”. The patient has the right to receive due to inaccurate or insufficient information about the medical service, regardless of the fault of the medical organization (Art. 1095 of the Civil Code of the Russian Federation, Art. 12 of the Law of the Russian Federation). Also, the provision of medical care without IDS can be a criterion for unlawful infliction of harm (Chapter 59 of the Civil Code of the Russian Federation).
- Budarin G.Yu., Ertel L.A. Realization of the right of citizens to informed voluntary consent within the framework of the current legislation of the Russian Federation // Medical Law. 2013. No. 4. S. 30 - 34.
(IDS) is a documentary evidence of the necessary procedure - informing the patient, confirming the consent of the patient or his legal representative to a specific medical intervention.
Before signing the IDS, the medical worker provides in an accessible form information about the goals, methods of providing medical care, the risks associated with them, possible options for medical intervention, its consequences, as well as the expected results of the provision of medical care.
Signing an Informed voluntary consent to medical intervention or writing a refusal of medical intervention is regulated by Art. 20 of the Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” (hereinafter referred to as the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation). Informed voluntary consent must be drawn up in writing, signed by a citizen, one from the parents or other legal representative, a medical professional and is contained in the patient's medical records.
Informed voluntary consent is issued when:
- receiving primary health care when choosing a doctor and medical organization for the period of their choice;For certain types of medical intervention, which are included in the list established by the authorized federal executive body.
Currently, this list is determined by the Order of the Ministry of Health and Social Development of the Russian Federation dated April 23, 2012 N 390n “On approval of the List of certain types of medical interventions for which citizens give informed voluntary consent when choosing a doctor and medical organization to receive primary health care.”
The IDS can be valid for the entire duration of the contract for the provision of medical services and applies to the medical worker whose signature is reflected in the IDS form.
Part 2 Art. 20 of the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, a restriction is established under which informed voluntary consent to medical intervention is given by one of the parents or other legal representative of the patient, namely:
For persons under the age of 15;
- in relation to persons recognized as incompetent;
- in relation to minors with drug addiction.
The legal representatives of a citizen, in addition to parents, are adoptive parents, guardians and trustees.
For the absence of an IDS, liability is provided in accordance with the legislation of the Russian Federation. The absence of an issued IDS can be considered:
- as a violation of licensing requirements in the implementation of medical activities (clause 5 a., c. Decree of the Government of the Russian Federation of April 16, 2012 No. 291 "On licensing medical activities"), which will entail administrative liability in accordance with parts 3, 4 of Art. 14.1 of the Code of Administrative Offenses of the Russian Federation.As a violation of clause 28 of Decree of the Government of the Russian Federation dated 04.10.2012 No. 1006 “On approval of the Rules for the provision of paid medical services by medical organizations”, which will entail administrative liability in accordance with Art. 14.8 of the Code of Administrative Offenses of the Russian Federation.
As a violation of the Civil Code of the Russian Federation and the Law of the Russian Federation of February 7, 1992 No. 2300-1 “On Protection of Consumer Rights”. Due to inaccurate or insufficient information about the medical service, regardless of the fault of the medical organization.
However, the Citizen or his legal representative has the right to refuse medical intervention or demand its termination. In case of refusal of medical intervention to the patient or his legal representative, in a form accessible to him, the possible consequences of such refusal should be explained.
In accordance with paragraph 8 of Art. 20 of the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, the procedure for issuing an IDS for medical intervention and refusal of medical intervention, including with respect to certain types of medical intervention, the form of the IDS for medical intervention and the form for refusing medical intervention are approved by the authorized federal executive body .
Some forms of IDS for medical intervention, including for various branches of medical care, are approved by orders of the Ministry of Health of the Russian Federation.
For each medical organization (not included in the list of IDS orders presented on the website), it is advisable to develop internal IDS forms for each specific medical intervention, taking into account all the necessary criteria for properly informing the patient about the upcoming medical intervention.
To date, the Order of the Ministry of Health of Russia dated December 20, 2012 No. 1177n “On approval of the procedure for giving informed voluntary consent to medical intervention and refusal of medical intervention in relation to certain types of medical interventions, forms of informed voluntary consent to medical intervention and forms of refusal of medical intervention”, which approved the forms of consent and refusal of medical intervention, which are mandatory for use by medical organizations only when implementing the program of state guarantees.
You can download an example of consent, download IDS for medical intervention and refusal of medical intervention by clicking on the link.
It is necessary to complete the IDS form:
1) in the provision of all types of medical care: primary health care; specialized and high-tech medical care; emergency; palliative care.2) under various conditions for the provision of medical care: outside a medical organization (at the place where an ambulance was called, in a vehicle during medical evacuation); on an outpatient basis, including when calling a doctor at home; in a day hospital; stationary.
3) in all forms of medical care: emergency medical care (in case of sudden acute diseases and conditions that threaten the patient's life); emergency medical care (for sudden acute diseases and conditions without obvious signs of a threat to the patient's life); planned medical care (for diseases and conditions not accompanied by a threat to the patient's life).
The following information is indicated in the form of the IDS or refusal of medical intervention: Name of the medical organization, full name. medical worker; FULL NAME. the patient and the legal representative of the patient; Legal substantiation of IDS; Features of the legal regulation of medical intervention; Name of medical intervention; The purpose of the medical intervention; Methods of rendering medical care; Possible options for medical intervention; Consequences of medical intervention; Risks of medical intervention; Estimated results of medical care; The right and consequences of refusing medical intervention; Additional specialized information (indicated in accordance with the requirements of the legislation of the Russian Federation for various types of medical services).
Medical intervention without consent is necessary:
- according to emergency indications to eliminate the threat to a person's life and if his condition does not allow him to express his will or there are no legal representatives;- in relation to persons suffering from diseases that pose a danger to others;
- in relation to persons suffering from severe mental disorders;
- in relation to persons who have committed socially dangerous acts (crimes);
- when conducting a forensic medical examination and a forensic psychiatric examination.
The decision is made by a board of doctors.
If it is impossible to convene a consultation, the decision is made directly by the attending physician, followed by notification of the head of the medical organization.
In fact, the IDS form, which is stored in the outpatient card or case history, with the timely implementation of the informing procedure itself, and not forgery in absentia, is an effective mechanism for protecting the doctor and the medical institution from unreasonable claims from the patient.
The difficulty associated with issuing an IDS lies in the fact that the legislation provides for the necessary minimum procedures for issuing an IDS. At the same time, the number of medical services and interventions is growing every year. And for each or almost each of them, it is desirable to issue an IDS in order to comply with the law.
How many of the patients understand the essence and meaning of medical terms, how many understand how and under what conditions manipulations are performed, what will be discussed, who will be present during the examination or manipulation.?
The design of the IDS form or the development of internal IDS forms for individual manipulations should be carried out on the basis of the recommendations set out in the relevant regulations. An incorrectly executed IDS form containing incomplete information cannot be a tool to protect medical workers and a medical institution. The development of internal IDS forms is a responsible matter, which our company is also involved in. At the same time, filling out the form and processing it at the reception entrance or sometimes at the reception staff (receptionist, administrators) is no less responsible process.
Often in practical medical activities, the question arises - is it possible to carry out a medical procedure or service without issuing an IDS, if the patient or his relatives are unwilling to sign the document.
The legislation, as always, indicates the reasons for providing assistance without IDS in the interests of the patient (in case of emergency indications) or in the interests of society (dangerous infections, socially dangerous acts or forensic examination), but there is no single conclusion on this issue.
However, the absence of a completed IDS form for the service provided is a violation of licensing requirements, a violation of the rules for the provision of paid medical services and a violation of the rights of the consumer of the service.
Refusal to sign the IDS form by the patient, without clear justification of the reasons, but the desire to receive the service leads to a conflict of interest. A medical institution and a doctor may be interested in providing a service, but without filling out an IDS form, both the doctor and the medical institution remain unprotected even from unfounded claims.
The solution is to formalize cases of refusal to sign the IDS by holding, albeit a short, but still full-time medical commission with the members of the VC fixing the circumstances of the patient's refusal to issue the IDS form, when informing. Thus obtain protection against unfounded claims and perform the service. Or refuse to provide a service to the patient, possibly losing the patient's favor and definitely losing the cost of the service provided (under CHI, VHI or for a fee).
OOO Med-YurConsult
Appendix No. 2
to the order of the Ministry of Health of the Russian Federation
dated December 20, 2012 N 1177n
(as amended on August 10, 2015)
The form
Informed voluntary consent to types of medical interventions, included in the List of certain types of medical interventions, on which citizens give informed voluntary consent when choosing doctor and medical organization to receive primary health care I, ___________________________________________________________________________ (full name of the citizen) "__________" ______________________________________________ year of birth, registered at the address: __________________________________________ (address of the citizen's place of residence or legal representative) give informed voluntary consent to the types of medical interventions included in the List of Certain Types of Medical Interventions , to which citizens give informed voluntary consent when choosing a doctor and medical organization to receive primary health care, approved by order of the Ministry of Health and Social Development of the Russian Federation of April 23, 2012 N 390n (registered by the Ministry of Justice of the Russian Federation on May 5, 2012 N 24082) (hereinafter - the List), to receive primary health care / receive primary health care by a person whose legal representative I am (unnecessary cross out) in _______________________________________________________________________________. (full name of the medical organization) The medical worker _________________________________________________ (position, full name of the medical worker) in a form that is accessible to me, explained to me the goals, methods of providing medical care, the risk associated with them, possible options for medical interventions, their consequences, including including the likelihood of complications, as well as the expected results of medical care. It was explained to me that I have the right to refuse one or more types of medical interventions included in the List, or demand its (their) termination, except as provided for by Part 9 of Article 20 of the Federal Law of November 21, 2011 N 323-FZ " On the fundamentals of protecting the health of citizens in the Russian Federation" (Collected Legislation of the Russian Federation, 2011, N 48, item 6724; 2012, N 26, item 3442, 3446). Information about the persons I have chosen, to whom, in accordance with paragraph 5 of part 5 of article 19 of the Federal Law of November 21, 2011 N 323-FZ "On the basics of protecting the health of citizens in the Russian Federation", information about the state of my health or the state of the person may be transferred, whose legal representative I am (strike out the unnecessary) ________________________________________________________________________ (full name of the citizen, contact phone number) __________ _____________________________________________________________ (signature) (F. AND ABOUT. citizen or legal representative of a citizen) __________ _____________________________________________________________ (signature) (full name of the medical worker) "__" ____________________________________________ (date of issue)