INFORMED CONSENT FOR AI-ASSISTED CLINICAL DOCUMENTATION

Effective Date: June 1, 2026

I. Purpose of This Form

This practice uses artificial intelligence (AI) tools to support clinical documentation. This form explains how those tools work across the services offered here — psychology, psychiatry, and occupational therapy — and what that means for your privacy. Please read it carefully before signing. You are welcome to ask questions at any time.

II. How AI Is Used in Psychiatry

How it works

During your psychiatric appointments, an ambient AI tool listens and generates a text transcript of the session. Additionally, during the session, your psychiatrist takes typed notes that may include available laboratory or study information. These notes and the transcript are used to create clinical documentation.

Is audio recorded?

The ambient AI processes speech in real time to generate text. The audio itself is not stored and cannot be played back by the clinician or anyone else. Only the text transcript is retained.

What AI sees

A text transcript of the spoken session and your psychiatrist's notes.

Who reviews notes?

Your psychiatrist reviews, edits, and approves all documentation before it is finalized.

What applications are used?

Heidi Health
OpenEvidence

III. Privacy & Data Practices

Secure Storage - All AI platforms used by this practice are HIPAA-compliant. Each platform has signed a Business Associate Agreement (BAA) with this practice, as required by federal law, legally obligating them to protect your health information. Data is encrypted in transit and at rest.

Use of Your Information - AI-generated content is used solely to support clinical documentation for your care. Your information is not shared with third parties for commercial purposes and is not used to train AI models.

Data Retention & Deletion - Only the text transcript is retained to support documentation, in accordance with applicable medical record retention laws.

Access to Your Records - You have the right to access your clinical records at any time under HIPAA. To make a request, contact your clinician or the practice administrator directly.

Voluntary Participation - Consent to AI-assisted documentation is voluntary for each service. You may decline or withdraw consent at any time, without affecting the quality of care you receive. If you decline, your clinician will use alternative documentation methods.

IV. Potential Risks & Limitations

• AI may occasionally misformat, misinterpret, or omit information. Your clinician reviews all documentation for accuracy before it is finalized.
• As with all electronic systems, a small inherent risk of data breach exists despite security safeguards. This practice takes all reasonable precautions to minimize this risk.
• If you believe any documentation contains an error, you may request a correction at any time.

V. Your Rights Under HIPAA

• Right to access your health records
• Right to request corrections to your records
• Right to receive a copy of this practice's Notice of Privacy Practices
• Right to file a complaint with the U.S. Department of Health & Human Services (HHS) if you believe your privacy rights have been violated

To exercise any of these rights, please contact your clinician or the practice administrator.

VI. Changes to this Notice

We reserve the right to revise or change provisions on this Notice. We will implement the new Notice provisions effective for all services provided and confidential information we maintain. The most current version of this notice will be available on our website at https://www.emilywoodmdphd.com/policies. The Notice will contain the effective date on the top of the first page.

VII. Consent Declaration

• ☐ I CONSENT to the use of ambient AI transcription during my psychiatric appointments. I understand that this form serves as my disclosure and acknowledgment that this tool may be active during sessions, that audio is not stored, and that only a text transcript is retained.
• ☐ I DO NOT consent to ambient AI. I understand my psychiatrist will use alternative documentation methods.

By signing below, I confirm that I have read and understood this form (or it has been read and explained to me), that I have had the opportunity to ask questions, and that my consent choices above are voluntary and accurately reflect my preferences.

Patient (or Legal Guardian if patient is a minor)

Signature: ___________________________________________

Date: ___________________________________________

Printed Name: ___________________________________________

Relationship (if signing on patient's behalf): ___________________________________________