HIPAA AUTHORIZATION FORM last updated October 08, 2025

1. AI-Driven Pre-Visit Symptom Deep Dive
By signing this form, you consent to the collection, use, and disclosure of your health data by ViClinic’s AI systems prior to your telehealth or EMR visit. Collected data (e.g., symptom descriptions, intensity, and related details) will be summarized and integrated into your medical record.
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2. Disclosure & Use
Information may be used for diagnosis, treatment, coordination, and decision support by your healthcare provider. Data is shared only as necessary to facilitate care delivery and stored securely in accordance with HIPAA.
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3. Security & Privacy Protections
ViClinic maintains secure, HIPAA-compliant data protocols and encryption for all AI-collected information.
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4. Revocation of Consent
You may revoke your consent at any time by contacting support@viclinic.com. However, revocation may impact your ability to use certain features of the service.
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5. Telehealth Informed Consent
By using ViClinic’s telehealth services, you agree to the integration of AI tools to streamline intake and care. Risks may include:
- Limited data coverage by AI, requiring physician clarification
- Technical delays in transmission or summarization
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6. Acknowledgment
By signing b or checking box, you acknowledge:
- Understanding of how ViClinic’s AI integrates into your care
- Consent to collection and use of health data
- Awareness of possible AI-related risks‍