Client consent for recording and use of a clinical documentation service

1. Parties and purpose

• I am the client or legal representative.
• My therapist, doctor, or other licensed clinician at: [Name of clinician or practice]
• uses an external clinical documentation service that receives audio from my sessions and helps create draft notes. The purpose is to support my care and the operations of the practice.

In this form, "clinician" means the therapist, doctor, or other licensed professional providing my care at this practice.

2. Recording of sessions

• My clinician may audio record my sessions, in person or by telehealth, in order to send the recording to the documentation service.
• I consent to the recording of my sessions for this purpose.
• I agree that everyone who takes part in a recorded session, including me, consents to the recording.
• I will tell my clinician if anyone else is in the room with me during a session.

3. How my information is used and shared

• My information may be used and shared by my clinician, the practice, and their service providers as needed for:
  1. treatment
  2. payment
  3. health care operations such as scheduling, supervision, quality review, and billing
• Service providers are required by contract to protect my information and to use it only for these purposes.
• My information is not sold for marketing.
• If my clinician or practice ever wants to use my information for purposes that require extra consent, such as some kinds of research, they will ask me separately.

4. Medical record and psychotherapy notes

• Only the clinical note that my clinician creates will become part of my official clinical record with this practice.
• Audio recordings and any machine generated transcripts are temporary working materials. They are used to help my clinician write the note and are not treated as part of the official record.
• Psychotherapy notes as defined in federal privacy rules are separate personal notes of the clinician about what was discussed in session. These separate notes are not created or stored by the documentation service. My clinician may keep those separate notes elsewhere if they choose.

5. Storage, security, and retention

• Audio and any temporary transcripts are stored on secure systems with technical and physical safeguards.
• Session audio and any temporary transcripts will be kept for about: [number] days
• After that they are deleted, except when a longer period is required for security, audit, or a legal hold.
• The clinical note that my clinician creates may be kept longer as part of my clinical record, according to the record retention rules that apply to this practice.

6. Substance use treatment if applicable

• This section applies only if my clinician or practice provides substance use disorder treatment that is subject to special federal rules.
• If that applies, I consent to the use and disclosure of my records for treatment, payment, and health care operations to my clinician or practice, to their documentation service, and to other service providers and health plans involved in my care as described in the Notice of Privacy Practices, until I revoke this consent in writing.
• I may revoke this consent at any time, except to the extent that actions have already been taken based on it.
• If this section does not apply, my clinician or practice may strike it out.

7. Right to refuse or revoke

• I can ask my clinician about options if I prefer not to be recorded.
• I may revoke this consent at any time by notifying my clinician or practice in writing. Revoking my consent does not change any use or disclosure that has already happened based on my earlier consent.

8. Children and legal representatives

• If I am signing as a parent, guardian, or other legal representative, I confirm that I have legal authority to consent for this client.
• If state law gives a minor the right to consent to some services on their own, the clinician or practice may also ask the minor to sign this form.

9. Electronic signature and acknowledgment

• I agree that my electronic signature on this form has the same effect as a handwritten signature.
• The practice may keep an electronic copy of this form, with the date and time my signature was recorded, as part of its records.