Sidekick:

Example Consent Form

Below is an example of an audio recording consent form. Please be sure to research regulations in your state to ensure any consent form you use in your practice covers any necessary requirements:

Audio Recording Consent Form

I, ______________________________, acknowledge and understand that

_________________________ (the “Provider”) will be using PredictionHealth’s AI scribing

software service (the “Software”), during our visits moving forward. This Software will record and

process the audio of our conversation to auto-generate the Provider’s documentation and

administrative work to help ensure the highest quality of care possible.

By signing this Audio Recording Consent Form, I expressly certify that I understand that:

A. The Provider will be using the Software to capture conversations between myself and

the Provider in order to auto-generate the Provider’s documentation and administrative

Work.

B. The audio will be processed by the Software and will record my protected health

Information.

C. The audio recording will be used for clinical purposes only, including treatment,

payment or health care operations in accordance with the Health Insurance Portability

and Accountability Act of 1996, as amended (“HIPAA”). It will not be used for any other

purposes, including, for example, sharing, selling or using the audio recording for

advertising purposes not in accordance with HIPAA.

D. The audio recording will be stored securely as part of my medical record in

accordance with the applicable security regulations of HIPAA.

I have read all of the information above, or it has been read to me. I have had the opportunity to

ask questions about it and any questions that I have asked have been answered to my

satisfaction. By signing below, I expressly consent to the use of the Software and to have the

audio of my visits recorded to support my Provider’s clinical work.

_____________________                ______________            _______________

Signature of Patient                               Date                                Date of Birth

If this Audio Recording Consent Form is being completed by a person with legal authority to act on the patient’s behalf, such as a parent or legal guardian of a minor health care agent, please complete the following:

_____________________________________________________

Name of Person Completing Form and Relationship to Patient

___________________________________          ______________          ________________

Signature of Person Completing Form                   Date                               Patient Date of Birth