Consent Form for Charity Care

Before proceeding we must inform you that we cannot provide legal advice to individual TMA members because Texas prohibits the "corporate practice of law" (Texas Government Code Ann. '81.101). In addition, the State Bar of Texas has ruled that corporate-employed attorneys may not provide legal services to customers of the corporation if a corporation receives fees that are, to any extent, compensation to the corporation for the attorney's legal services to the customers. To do so is a prohibited form of "fee-splitting" (Ethics Opinion 498, January 1995). The fact that TMA is a non-profit corporation does not seem to change the conclusion. However, we can provide general legal information about this topic. Because your facts may vary, you should contact your own retained counsel for true legal advice and representation.

The following consent form is an example to be used for volunteer health care providers in non-hospital charitable organizations.

Revised April 2006

CONSENT FOR CHARITY CARE

I, ___________________________, acknowledge that Dr. __________________ is a volunteer health care provider, and is not administering care for or in expectation of compensation.  I also understand that as a volunteer health care provider, the physician is immune from civil liability for any act or omission resulting in death, damage, or injury as long as the volunteer acts in good faith and in the scope of his or her duties within the organization in providing the health care services. 

Furthermore, I realize that the civil liabilities of both the charitable organization and an employee of the charitable organization are limited to money damages of $500,000 for each person, $1,000,000 for each occurrence of bodily injury or death, and $100,000 for each occurrence of injury to property.  These limits apply to the employee and the organization separately; they are not aggregate limits. 

_______________________________
Patient's signature                   

_______________________________
Date

 

Prepared by: TMA Office of the General Counsel

NOTICE: This information is provided as a commentary on legal issues and is not intended to provide advice on any specific legal matter. This information should NOT be considered legal advice and receipt of it does not create an attorney-client relationship. The Office of the General Counsel of the Texas Medical Association provides this information with the express understanding that 1) no attorney-client relationship exists, 2) neither TMA nor its attorneys are engaged in providing legal advice and 3) that the information is of a general character. Although TMA has attempted to present materials that are accurate and useful, some material may be outdated and TMA shall not be liable to anyone for any inaccuracy, error or omission, regardless of cause, or for any damages resulting therefrom. Any legal forms are only provided for the use of physicians in consultation with their attorneys. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought.


Comment on this (Must be logged in to comment)

Add Comment

Text Only 2000 character limit

Looking for more?