Patient Consent for AI-Assisted Documentation

Patient name: __________________________________________

Date of birth: __________________ Date: __________________

Proposed use for my visit

Haven proposes to use AI for the following purpose(s). Staff must select the actual use before asking me to sign:

☐Drafting a visit note from information entered by a clinician; no visit audio captured.

☐Transcribing and drafting a note from visit audio; audio capture is involved.

☐Organizing intake information I provided for clinician review.

☐Other specifically described use: ___________________________________________

AI vendor or tool used: _________________________________________________

If audio is captured: Will the audio file be retained after the note is finalized?

☐No ☐ Yes — explain retention and access: _________________________________

Risks, protections, and alternatives

Haven will explain the proposed workflow before use. Any recording or audio capture requires the consent of all parties when required by law. No public or consumer AI account may be used to process my PHI unless Haven has established the privacy and security arrangements required for that use.

AI can make mistakes, omit context, or misinterpret speech. A clinician will review its output rather than treating it as an independent medical conclusion. Haven will handle information used with its approved tool under its HIPAA Notice of Privacy Practices and applicable law.

I may decline this optional AI use. Haven will document my visit through its usual process. Declining AI assistance will not, by itself, affect my eligibility for evaluation or care. I may ask questions before deciding and may withdraw this consent for future use by telling Haven. Withdrawal cannot undo processing already completed.

This consent does not authorize Haven to use my identifiable information to train a public AI model, sell my information, publish my visit, or use my information for advertising.

My decision

☐I consent to the selected AI use described above.

☐I decline the selected AI use described above.

Patient or authorized representative signature: ______________________________

Date: __________________

If signed by a representative

Printed name: _________________________________________________

Relationship and legal authority: _________________________________

Staff

Staff member explaining the proposed use: _________________________________

Date: __________________