Sample Consent Form

 

Notice: This sample document and the information in it is presented solely as an example and to be used as a general guide. It is not intended as legal advice. This sample document is not a substitute for legal advice and may not be applicable to, or accurate for, your individual practice setting. By using this sample document, you hereby agree to release and hold harmless Eleos Health, Inc., from any liability arising under or relating to this “Sample Consent Form for Recording” document, whether arising in contract, equity, tort or otherwise. 

[Enter the clinic's name here]

[Enter the clinician/provider name here]
 

I, ________________, agree to participate in treatment which involves video and/or audio recording of services.

_______________

Client's Full Name

 

_______________

Client's Consenting Adult Full Name
(if minor)

________________

Relationship

 

 

________________

Relationship

I understand that services will be recorded (audio and/or video) and observed solely by my clinician. This will not be valid only in the case I have expressly consented and signed a release of information for others to view my recording, or unless another exception to confidentiality applies. I understand that recordings may include protected health information that is protected under HIPAA. I understand that the maintenance of this recording as a health record is the responsibility of my clinician and/or their clinic and follows the guidelines outlined in the general clinic consent form. 

My agreement and participation or that of listed family members is knowing and voluntary. Further, I understand that I may withdraw my consent for recording or ask questions about my recording at any time. I acknowledge that I have been provided with a HIPAA Notice of Privacy Practices.  

_______________

Client Signature

 

_______________

Client/Legal Guardian Signature
(if client is a minor)

_______________

Clinician Signature

________________

Date

_________________

Date

________________

Date

Security, Privacy & Compliance

Eleos Health is a unique AI-assisted platform for therapists, as such, we treat personal health information (PHI) in the most thoughtful way possible. Eleos Health is HIPAA compliant and upholds privacy and data protection to the highest standard. On this page, you can find our Privacy Policy and Security page.

 

We know these documents might be intimidating so we decided to write the essence of them here, in a common language (this is not a replacement for the language in the agreed policies).

We take patient data privacy seriously.

We understand that trust is critical when it comes to patient/therapist relationships, so we do not take any shortcuts to protect patients' information. Our entire platform is HIPAA compliant and held to the utmost privacy standards, including the encryption of data on record, in transit, and at rest. We don’t stop with HIPAA and we take the extra step to make sure your data is safe. This includes continuous monitoring of our system, internal and external audits, and holding one of the highest standards for information security.

How do we store and handle PHI?

PHI goes through the following process:

Recorded -> Encrypted -> Analyzed -> Populated back into the therapist’s dashboard for 90 days -> After 90 days, the information is de-identified/deleted.
 

We believe 90 days is sufficient for most providers to review the recording and its analysis, however, if a provider wishes to save the recording for a longer period of time, the provider can download the recording and it will be downloaded to their device. At this point, we have no responsibility for the handling of that recording and you must obey the relevant rules and regulations regarding holding of PHI. In any case, the individual user is not responsible for maintaining records (e.g., clinical training programs). His administrator/supervisor will be granted access to enable/disable the option to download the recording for his users/trainees.

The way we use personal information

In order to help clinicians provide you with state-of-the-art behavioral care, we use voice analysis and voice-enabled assistant that drives clinical improvement and efficiency, we need to analyze PHI on the cloud. We are HIPAA compliant and stand in the highest privacy standards. 

The security of your data is our top priority so we are committed to providing a highly secure, HIPAA compliant, and reliable environment you can trust.

Eleos Health uses the PHI to improve clinicians' services that enable them to provide better care. We do not sell or license information, recordings, or any other form of data to anyone. 

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Improving behavioral therapy, one session at a time.

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Cambridge, MA

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