AIDA AI – Authorization and Consent

Who we are. AIDA AI (“AIDA”) was created to assist healthcare providers efficiently diagnose and treat substance abuse disorders (“SUD”) using artificial intelligence. AIDA uses cutting-edge technology to suggest diagnoses and treatment plans to healthcare providers within seconds using patient interaction data. By analyzing patient interaction data, we can identify patterns and trends that inform more accurate diagnoses and personalized treatment plans. Our goal is improve long-term recovery and overall quality of life for those with SUD.

 

Authorization. I hereby authorize the healthcare provider listed below to disclose my Protected Health Information, as that term is defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as described below to AIDA consistent with this authorization. I understand that this authorization is voluntary. No individual has coerced me into signing this authorization, and I am providing this authorization under my own free will.

 

Information to be disclosed. I understand that AIDA works by analyzing my speech patterns alongside information included in my medical record. To do this, AIDA must listen to and record the conversation I have with my healthcare provider. Specifically, I agree that this form authorizes the recording of my patient interaction and the release the following Protected Health Information to AIDA, including substance abuse treatment records governed by Part 2:

 

• Treatment notes, patient interaction summaries, and other common medical record documentation made by the physician, nurse, or other ancillary personnel for the entire time I was treated by the healthcare provider listed below

• Audio recording of patient interactions

 

I understand that Protected Health Information may include information that is created both before and after the date of this authorization.

 

Purpose of the use or disclosure. I authorize AIDA to use and disclose all, or any part of, the Protected Health Information under this authorization to: (i) analyze and suggest diagnoses and treatment plans to my healthcare provider, (ii) create de-identified health information in accordance with HIPAA, and (iii) develop, train, test, improve and operate AIDA’s products and services, including without limitation, AIDA’s current and future artificial intelligence and/or machine learning algorithms and/or models. I understand that, consistent with this authorization, AIDA may de-identify my Protected Health Information, and that if all information that does or can identify me is removed from my health information, the remaining information will no longer be subject to this authorization and may be used or disclosed for other purposes.

 

Revocation. I understand that I may revoke my authorization at any time by sending written notice to AIDA at info@myaida.ai. I understand that my revocation will be effective upon receipt and AIDA will cease the collection of my Protected Health Information, except to the extent that any party has acted in reliance on this authorization. I understand that I have the right to refuse to sign this authorization.

​

Acknowledgments. I acknowledge that I have read and understand this authorization and that I have had an opportunity to discuss it with my healthcare provider. I understand that I have a right to receive a copy of this authorization and may send a request for a copy to AIDA at info@myaida.ai. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this form. I acknowledge that my authorization will remain valid as long as I obtain services from AIDA unless earlier revoked by me or as otherwise limited by applicable law. I understand that once information is used or disclosed under this authorization, there is a potential for it to be redisclosed and may no longer be protected under federal or state privacy law. However, I further understand that state law may prohibit the person receiving my information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law.

 

By signing this authorization, I affirm that I am at least 18 years of age and have the legal capacity to provide effective consent.

​

Name:

Signature: 

Healthcare provider making disclosure: 

Date: 

Relationship to individual: 

​

​​

​