Authorization & Consent for AI Assistance

PATIENT AUTHORIZATION AND CONSENT FOR USE OF ARTIFICIAL INTELLIGENCE (AI) TOOLS

*Please read this document carefully before signing*

This document explains how artificial intelligence (“AI”) tools may be used in connection with your care and related administrative services at Haven Health & Wellness (DepressionandAnxietyrelief.com) (the “Practice”). It also describes your rights and choices regarding such use. If you have questions, please ask us before signing.

1. Purpose of This Authorization.

The purpose of this Authorization and Consent is to inform you of, and obtain your permission for, the use of artificial intelligence-assisted technologies by the Practice and/or its clinician(s) in connection with your treatment, care coordination, documentation, and administrative operations. AI tools are used to support efficiency, accuracy, and organization but do not replace professional judgment or clinical decision- making.

2. Definition of Artificial Intelligence (AI).

Artificial intelligence refers to software systems or digital tools designed to assist humans by performing tasks such as, but not limited to, recording, transcribing, summarizing, organizing, or analyzing information. AI tools may operate automatically or with human oversight and are used as support tools only, not as independent decision-makers.

3. Authorized Uses of AI.

By signing this form, you authorize the Practice and/or its clinician(s) to use AI-assisted tools for purposes that may include, but are not limited to:

• Recording, transcribing, or summarizing sessions or portions of sessions

• Assisting with clinical documentation, including progress notes, treatment summaries, and records

• Supporting administrative tasks such as scheduling, billing support, chart organization, workflow optimization, and quality improvement

• Enhancing accuracy, efficiency, and continuity of documentation and practice operations

AI tools may be used during or after sessions and may process information you provide verbally, in writing, or electronically.

4. No Replacement of Professional Judgment.

By singing this form, you understand, acknowledge, and agree that:

• AI tools do not provide medical, mental health, or therapeutic services

• AI tools do not diagnose conditions, determine treatment plans, or make clinical decisions

• All clinical judgment, professional decisions, diagnoses, recommendations, and treatment remain the sole responsibility of your clinician

• Your clinician reviews, evaluates, and finalizes all AI-assisted documentation

• The use of AI does not alter the clinician’s professional duties or standard of care

5. Confidentiality, Privacy, and Safeguards.

The Practice takes reasonable administrative, technical, and organizational measures to protect your information when AI tools are used. Such measures may include, but are not limited to:

• Selecting AI platforms with privacy, security, and confidentiality safeguards

• Limiting access to your information to authorized individuals

• Using AI tools in a manner consistent with applicable privacy and confidentiality obligations

You understand that while safeguards are implemented, no electronic system can guarantee absolute security, and there is always some risk associated with the electronic processing and storage of information.

AI tools used by the Practice may involve secure third-party systems that process information as part of providing their services. These vendors are expected to maintain confidentiality and comply with applicable privacy and security standards. AI vendors are not authorized to use identifiable information for unrelated purposes such as product training or development unless separately permitted by law or agreement.

6. Limitations, Risks, and Technology Considerations.

By signing this form, you acknowledge and understand that:

• AI-generated content may contain inaccuracies, omissions, or errors

• AI systems may occasionally malfunction, experience outages, or produce unintended results

• Documentation supported by AI is reviewed by your clinician, but errors may still occur

• Technology-assisted documentation does not eliminate all risk related to recordkeeping

• You agree that the use of AI as a support tool does not create any guarantee of accuracy or outcomes.

7. Ownership and Use of Records.

All clinical records and documentation created in connection with your care, including, but not limited to, records created with AI assistance, remain the property of the Practice and are maintained in accordance with applicable laws and professional standards.

8. Voluntary Consent and Right to Revoke.

Your consent to the use of AI is voluntary. You have the right to:

• Ask questions about how AI tools are used

• Request additional information or clarification

• Revoke or withdraw this authorization at any time by providing written notice to the Practice via email at info@depressionandanxietyrelief.com.

If you revoke consent, the Practice will continue to provide all scheduled services and care without interruption. In such cases, the Practice may document your care manually, use non-AI-assisted methods for administrative tasks, or employ alternative workflows to maintain accurate records.

9. No Denial of Care.

Your decision to refuse or revoke consent will not affect your access to care, treatment, or any services provided by the Practice, but certain processes may take additional time or require alternative procedures to ensure proper documentation and administrative handling.

10. HIPAA Notice And Authorization.

a. Use and Disclosure of Protected Health Information (PHI). If applicable, AI tools may process information that constitutes Protected Health Information (“PHI”) as defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its implementing regulations. The Practice may use or disclose PHI through AI-assisted tools solely for purposes related to treatment, payment, healthcare operations, and administrative support, in accordance with applicable law.

b. Safeguards and Business Associates. Where required, the Practice uses AI vendors that provide appropriate privacy and security safeguards and, when applicable, enter into Business Associate Agreements as required by HIPAA.

c. Patient Rights Under HIPAA. You retain all rights provided under HIPAA, including the right to: (i) Access and request copies of your records; (ii) Request amendments to your records; and (iii) Receive an accounting of certain disclosures. The use of AI tools does not diminish or waive any HIPAA rights.

11. Acknowledgment and Authorization.

By signing below, you acknowledge and agree that:

• You have read (or have had read to you) and understand this Authorization and Consent form

• You have had the opportunity to ask questions and all of your questions have been answered to your satisfaction

• You voluntarily authorize the use of AI-assisted tools as described above