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sample Consent
Consent to Use Ambient AI Scribe Technology During Your Visit
Purpose
Our practice uses a secure ambient AI scribe tool to help your doctor focus on you — not the computer. This technology listens passively during your visit and automatically generates a clinical note, allowing your physician to maintain eye contact and give you their full attention.
Privacy and Security
- No identifying data are retained beyond your official medical chart entry.
- The AI scribe operates under strict HIPAA-compliant security measures.
- The system cannot be used outside the encounter, and all data are automatically purged after processing.
Your Rights
- You have the right to opt out of the AI scribe at any time.
- Opting out will not affect the quality of your care. Your physician will simply document the visit manually.
- You may ask questions at any time about how this technology works or how your information is protected.
By signing below, I voluntarily consent to the use of the ambient AI scribe technology during my encounter today.
Patient Name: ______________________________________
Date: _______________________