Your AI Scribe Patient Consent Form
Here it is — a ready-to-use, HIPAA-aware consent form. Copy the text below into your intake packet or EHR, customize any details with your counsel, and you’re covered.
Already on BodySite? You don’t need to copy anything — this consent form is already built into your account, ready to capture and store digitally at check-in. Just turn it on in your settings.
Form template · Retain for a minimum of 6 years
Consent to Use an AI Scribe During My Visit
Please read this form and ask any questions before signing. Your care will not change if you decline.
What we are asking
During your visit, your clinician would like to use an AI scribe — software that listens to the conversation between you and your clinician, creates a written transcript, and drafts the clinical note for your medical record.
How it works
- Audio is captured only while the tool is turned on, and only during your appointment.
- The audio is converted to a transcript and used to draft an encounter note.
- Your clinician reviews and edits every note before it becomes part of your medical record. The AI does not make medical decisions.
Your privacy is protected
- The recording and transcript are Protected Health Information under HIPAA and are safeguarded like the rest of your record.
- Our AI vendor operates under a signed Business Associate Agreement and may not use your information for any other purpose.
- Audio is used to generate your note and is then deleted or de-identified per our retention policy. Your information is not sold and is not used to train AI models without separate, explicit authorization.
Your rights
- Consent is voluntary. You may decline and receive the same quality of care.
- You may withdraw consent at any time, including during the visit — just tell your clinician and the tool will be turned off.
- You may ask questions about the tool, the vendor, and how your information is stored at any time.
A note on recording laws. Some states require every person in a conversation to agree before it is recorded. By signing below you are giving that consent for the purpose described above. You may revoke it at any time.
Your decision
☐ I CONSENT to the use of an AI scribe as described above.
☐ I DECLINE. Please do not use an AI scribe during my visit.
| Patient name (print) · Date of birth |
| Patient signature · Date |
| Personal representative signature (if applicable) · Relationship to patient |
| Clinician or staff name · Practice / location |
This consent supplements, and does not replace, the practice’s Notice of Privacy Practices and general consent to treatment. Retain in accordance with applicable HIPAA documentation requirements (minimum 6 years).