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Patient Resources / AI Informed Consent

AI Informed Consent

How we use artificial intelligence in your care, your privacy protections, and your rights — please review and sign before or at your visit.

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This form seeks your informed consent to allow Endocrine & Diabetes Plus Clinic of Houston (“Practice”) and its staff to use artificial intelligence and machine learning technologies (collectively, “AI”) as part of your healthcare services, which may include assessment, diagnosis, treatment planning, clinical decision support, documentation support, operational tasks related to your care, access to such services, and interactions with our office.

1. Benefits and Risks of AI Use

  1. AI tools may analyze clinical data (such as, but not limited to, medical history, symptoms, images, labs, and other records) to generate recommendations or insights to assist your practitioner.
  2. AI is intended to augment, not replace, the professional judgment of your practitioner. Your practitioner may accept, modify, or disregard AI outputs, and final decisions about your diagnosis and treatment are made by your practitioner.
  3. Potential benefits of AI tools can include improved diagnostic accuracy, detection, assistance, more personalized treatment planning, reduced delays, additional documentation detail, and potential overall improvements in efficiency.
  4. Potential Risks and Limitations:
    • AI may generate inaccurate, incomplete, or biased outputs.
    • Technical errors, system outages, or cybersecurity incidents may occur.
    • AI performance can vary by population or data quality.
    • Explanations of AI outputs may be limited.
    • Residual privacy risks may exist despite safeguards.
  5. Practitioner oversight, validation processes, quality assurance, and security safeguards can be implemented to reduce, but cannot eliminate, potential risks.

2. Confidentiality and Data Use

  1. Your protected health information (“PHI”) will be used and disclosed in compliance with applicable privacy and security laws, and with Practice’s privacy policies.
  2. In some instances, data used for AI may be de-identified.
  3. Some AI tools may be provided by third-party vendors under agreements requiring privacy, security, and permitted-use restrictions.

3. Patient Rights

  1. By signing below, you acknowledge that your questions, if any, about the role of AI in your healthcare experience have been addressed to your satisfaction.
  2. You may decline AI use or withdraw your consent at any time without penalty or impact on your access to medically necessary care by providing written notice to Practice; however, withdrawing consent will not affect AI uses that have already occurred.
  3. If you believe you have been unfairly impacted by a consequential decision involving AI, you may seek information about that decision from your practitioner and request the decision be reconsidered.

Choosing not to consent does not change your care. If you'd prefer your provider not use AI-assisted tools during your visit, just let our staff know — you will receive the same attentive care and treatment options either way.

Sign This Form

Print this page or download the PDF to read, initial, and sign — bring it to your next visit or return it to our front desk. You're also welcome to review it on-screen and sign in office.

⬇️ Download PDF

Acknowledgment and Consent

Please read and initial each statement:

Initials
I certify this form has been fully explained to me, that I have read it or have had it read to me, that the blank spaces have been filled in, and that I understand its contents.
Initials
I understand the potential benefits and risks of AI use.
Initials
I consent to the use of AI as described in this form.
Signature
Date
Patient Name (Printed)
Date of Birth

If someone other than the patient is signing this form, indicate the name of the person, title, and authority to sign this form below.

Name
Title / Relationship to Patient
Authority to Sign Document

Questions?

If you have questions about how AI is used in your care or about this form, please ask your provider or call our office at 832-968-7003. For a plain-language overview of how we use these tools, see AI in Your Care.

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