Patient Consent Form-Canada

Patient Consent Form

Our office utilizes advanced AI (artificial intelligence) assisted charting to enhance efficiency and accuracy.

Your Privacy and Data Security is Our Priority.

Empathia.ai strictly complies with Canadian privacy laws, including the Personal Information Protection and Electronic Documents Act (PIPEDA) alongside all applicable provincial laws, including but not limited to the *Personal Information Protection Act* (PIPA) of British Columbia.

You retain the right to withhold and withdraw consent for the use of AI-assisted charting at any time. Alternative documentation methods are available.

Empathia

Empathia has created a technological solution aimed at enhancing the documentation process in medical encounters. This technology, known as Empathia Ambient Charting, captures the dialogue between healthcare providers and patients during appointments and leverages advanced Artificial Intelligence (AI) to generate consultation notes and other clinical documentation for clinicians. By implementing this technology, Empathia aims to assist your healthcare provider in offering:

• Providers more time to focus on patient care

• Highly accurate and detailed patient clinical notes

Committed to delivering the highest standard of care to both patients and physicians, Empathia places utmost importance on respecting individual rights and privacy. This initiative underscores our dedication to advancing healthcare services through innovation and excellence.

Purpose of Data Collection

The purpose of using Empathia is to improve the accuracy and efficiency of medical documentation, allowing your healthcare provider to spend more time focusing on your care. The data collected will only be used to create and improve medical documents associated with your care and treatment.

Information Recorded

• Conversations between you and your healthcare provider during medical visits

• Relevant personal health information disclosed during these conversations

• Any additional notes or information provided by your healthcare provider (this is not from the patient)

How the Information is Used

• To accurately document the details of your medical visits

• To assist healthcare providers in creating progress notes and other clinical documents

How is your information stored and who has access to it

Your personal information is stored on secure servers fully encrypted. These servers are kept in locations with strong security measures similar to those in the financial industry .

Our security technology is up to date and aligns with industry best practices. Only healthcare providers, necessary administrative and support persons involved in your care have permission to access your information.

We may also work with trusted third-party service providers for secure data storage and protection. Your data will be stored in cloud services located within Canada. Access is strictly limited to those who have a responsibility to manage and safeguard your data, in compliance with Canadian laws on personal health information protection.

We may use aggregated data, with no identifying details, to improve healthcare services. This use is permitted by law because it does not jeopardize patient privacy and can help us enhance the quality of healthcare.

Privacy and Security

We comply with Canadian privacy laws, including the Personal Information Protection and Electronic Documents Act (PIPEDA) or applicable provincial legislation such as Ontario’s Personal Health Information Protection Act (PHIPA), British Columbia’s Personal Information Protection Act (PIPA), respecting the confidentiality and security of your personal health information.

Consent

By signing this form, you provide consent to your Healthcare Institution and its authorized healthcare providers to use Empathia during your medical visits. You understand that this technology is designed to record and process your conversations for the sole purpose of creating medical documentation.

Withdrawal of Consent

You have the right to withdraw your consent to the recording of your medical visits at any time by notifying your healthcare provider. Upon withdrawal, no further recordings will be made, and you will be offered alternative methods of documentation.

Patient Acknowledgment and Agreement

I have read and understood the above information regarding the use of Empathia as part of my medical care. I have had the opportunity to ask questions and have had them answered to my satisfaction. I agree to the use of conversational recording technology as described above. I understand that my consent is voluntary and that I can withdraw my consent at any given point.

Patient Name: ___________________________________

Date of Birth (DD/MM/YYYY): _______________________

Personal Health Number: ___________________________

Other ID (if applicable): _____________________________

Patient Signature Date