What is it?

IMPORTANT NOTES:

• This AI Patient Consent Form does not replace your regular Informed Consent Form (also called Consent to Treat), HIPAA Notice of Privacy Practices, or any other required patient authorizations. It’s used in ADDITION to those forms.
• This form is for licensed practitioners when working with patients. This is NOT the correct form if you’re a “coach” working with “clients” across state lines. If you’re a coach, use the DIY AI Client Consent Form here instead, as it contains different language necessary for coaches. These forms are not interchangeable.
• Some state laws require that patients be allowed to decline AI-assisted analysis, note-taking, or audio or video recordings so this form allows patients to choose.
• This form states that you will have an AI Governance Policy, maintain human oversight, and have privacy safeguards to follow the law and reduce your liability - unlike generic AI disclosures. If you need an AI Governance Policy for Licensed Medical Practitioners, you can get it here.
• Additional state-specific AI disclosures or consent requirements may apply so please know your applicable laws. State laws are evolving frequently when it comes to AI.

Who needs it?

All licensed medical practitioners working with patients including:

• Physicians (all types), nurse practitioners and physician assistants
• Integrative, Functional, and Lifestyle physicians
• Chiropractic physicians
• Acupuncturists
• Naturopathic doctors
• Therapists, counselors and social workers
• Registered dietitians + licensed nutritionists
• Physical therapists, occupational therapists, speech therapists
• Nurses & Nurse Coaches working independently under their Nursing Practice Act
• Dentists
• All licensed medical practitioners using AI-assisted tools in patient relationships

Client Love

When do you need it?

Use this form if you're a licensed medical practitioner using AI to:

• analyze patient labs, biomarkers, health histories, or other clinical data.
• transcribe patient visits or use note-taking tools - including telehealth visits.
• draft patient education materials, clinical summaries, or care plans - even only using AI behind the scenes.
• communicate with patients in your EMR using AI tools.
• use de-identified patient data for clinical research or professional education.
• improve your practice's AI systems.

Why do you need it?

This AI Patient Consent Form helps you:

• Get written patient consent to AI-assisted care - so patients understand how AI is being used in your practice.
• Protect patient privacy and health data - by clearly explaining AI data use, HIPAA safeguards, and confidentiality protections.
• Set clear boundaries around AI use - including human oversight, clinical decision-making, and patient rights.
• Reduce legal risk from AI-assisted tools - by disclosing potential AI errors, inaccuracies, bias, and data security risks.
• Get permission for AI-assisted recordings - with patient opt-in choices for audio and video recording during visits.
• Protect your IP - including proprietary materials, AI-assisted workflows, and clinical systems.
• Build patient trust through transparency - so your patients feel informed, respected, and empowered when AI is used.
• Be energetically aligned in your sacral chakra by creating clear boundaries + expectations around AI use in your practice.

This form helps reduce risk for both you and your patients - so you can embrace AI with more clarity and confidence while keeping patient care at the heart of your practice.

What’s included in the DIY package?

• AI Patient Consent Form Template

• Easy-to-edit doc.
• Fill in the blank format you can use right away.
• Plain English - no confusing legalese. 
• Created with care + Legal Love™.