Informed consent for digitally assisted medical analysis through algorithms – Template

Informed consent for the use of state-of-the-art digital assistance in the process of oncological medical analysis OncoexpertAI

  • Date of consent:  23/05/2025
  • Time of consent: 10:46:05
  • OncoexpertAI Order Number (request reference): 800
  • Service ordered: OncoExpertAi Emergency Analysis

Service Applicant Identification Data:

  • Email address (mandatory for communication and report delivery): bige@mailinator.com
  • Name and surname or pseudonym: Sebastian Ardelean

Expression of Consent

By completing and submitting this form, the undersigned, identified by the email address and order number mentioned above, hereby express my informed, voluntary, and explicit consent for:

  1. Use of an advanced digitally assisted technique system (hereinafter referred to as the “AI system”) as a support tool for Dr. Onisim Florin in the oncological medical analysis requested by order no. <%fieldname19_value%>.
  2. The processing of my personal data, including sensitive medical data contained in the documents that I will provide (or have already provided), for the exclusive purpose of conducting digitally assisted oncological case analysis using advanced algorithms, in accordance with the contracted service..

 

Information Regarding the AI System and the OncoexpertAI Service

I understand and agree to the following:

  • Main purpose of the AI system: The AI system is used to assist Dr. Onisim Florin in the advanced analysis of medical data, connecting with updated international information databases (studies, clinical guidelines) regarding the main condition, complications, and associated diseases, with the aim of supporting the development of a detailed medical perspective and identifying proposals for personalized therapeutic recommendations.
  • How the AI system works: Advanced processing of provided medical data, correlation of information, and identification of relevant patterns.
  • Limitations of the AI system and the service:
    • The AI system is a support tool and does not replace the expertise and medical judgment of Dr. Onisim Florin or my attending physician. AI is associated with human medical analysis.
    • The OncoexpertAI analysis has an informational and decision-support role and does not constitute a final diagnosis, nor does it replace a direct medical consultation with my attending physician.
    • The final medical decision regarding diagnosis and treatment will always be made by my attending physician, in collaboration with me.
    • Although all efforts are made for accuracy, there is a theoretical possibility that the AI system may generate information that could be interpreted as incorrect or incomplete; this risk is reduced through human control and validation performed by Dr. Onisim Florin.
  • Data used by the AI system: The processed data will be that contained in the medical documents (e.g., symptoms, laboratory test results, histopathological and imaging reports, medical history, information about previous treatments and associated diseases) that I have uploaded or will upload for analysis, according to the instructions on the OncoexpertAI platform.

 

Potential Benefits of Using the AI System in the OncoexpertAI Analysis

  • May contribute to the faster identification of possible health problems or relevant aspects.
  • May provide an additional perspective and updated information to my attending physician and me.
  • May support a more detailed and complex analysis of my medical data.
  • May help identify personalized therapeutic options based on the latest scientific evidence.

 

Potential Risks of Using the AI System and the Service

  • The theoretical possibility that the AI system may generate suggestions requiring careful validation and interpretation by Dr. Onisim Florin and subsequently by my attending physician.
  • The possibility that the information in the report, if not discussed and integrated into the complete clinical context by my attending physician, may be misunderstood or improperly applied by me.
  • Inherent risks of any digital system regarding data security, although OncoexpertAI implements appropriate technical and organizational measures to minimize them, as detailed in the privacy policy.

 

Protection of My Personal Data

  • I understand and agree that my medical and personal data will be processed by OncoexpertAI and the AI system in accordance with legal provisions on personal data protection, including the General Data Protection Regulation (GDPR) and applicable Romanian legislation.
  • I have read and agree to the OncoexpertAI platform’s privacy policy, which details how my data is collected, used, stored, and protected, as well as the storage period.
  • OncoexpertAI will implement appropriate technical and organizational measures to ensure the security and confidentiality of my data.
  • I confirm that my medical data provided within this request will not be used for further training or improvement of the AI system used by OncoexpertAI.
  • I have been informed of my rights as a data subject, as detailed in the privacy policy, including the right of access, rectification, erasure, restriction of processing, data portability, and the right not to be subject to a decision based solely on automated processing that produces significant legal effects concerning me (subject to legal exceptions).

 

Right to Refuse or Withdraw Consent

  • I understand that I have the right to refuse to provide this consent. Refusal will result in the impossibility of providing the OncoexpertAI service, as it relies entirely on the use of the AI system and the processing of my medical data. In this case, a traditional medical consultation is recommended.
  • I also understand that I have the right to withdraw my consent for the use of the AI system and the processing of my data at any time, by written notification to OncoexpertAI. Withdrawal of consent will not affect the lawfulness of processing based on consent before its withdrawal but will lead to the immediate cessation of any ongoing analysis and the impossibility of providing the report (if it has not already been completed and delivered).

 

Questions and Clarifications

I declare that I have been given the opportunity to ask questions regarding the use of the AI system and the terms of this consent (through the information on the site and the contact page) and that I have understood the information presented in this document.

 

Patient/Applicant’s Declaration of Consent

By checking the box below and submitting this form, I declare the following:

  1. I have carefully read, fully understood, and agree to all the information and conditions presented in this “Informed Consent for the Use of Artificial Intelligence in the OncoexpertAI Oncological Medical Analysis Process” document.
  2. I freely, informedly, and unequivocally express my consent for the use of the AI system in my oncological medical analysis and for the processing of my personal data (including medical data) for the purpose of providing the OncoexpertAI service requested via order no. [Order Number], under the conditions described above and in accordance with the platform’s terms and conditions and privacy policy.
  3. I confirm that I am at least 18 years of age and have full legal capacity or, if I am acting on behalf of another person (e.g., a minor, a person under guardianship), I declare that I am their legal representative and have the right to grant this consent on their behalf.
  4. If I have opted for an analysis under a pseudonym, I confirm that the chosen pseudonym is the one mentioned above and that I assume responsibility for this agreement under this identification, while also being responsible for the correct and complete anonymization of the medical documents I provide.
[ I have accepted ] I check here to confirm the above statement and give my consent.