Informed Consent/ Disclosure for Independent Psychiatric Assessment/Release of Information

CLAIMANT NAME  

CLAIMANT PHONE NUMBER & E-MAIL ADDRESS (REQUIRED FOR VIRTUAL ASSESSMENT ONLY):  

Copy of Claimant Identification Received:

Driver’s License
Health Card
Other

 

I, the undersigned, provide consent to ‘the Assessor’, , who has been retained by ‘the Third Party’ (Independent Medical Evaluation Company, Insurer, Lawyer, Employer, etc.), to conduct a thorough unbiased Psychiatric Assessment of me in order to assist those adjudicating my claim.

I also authorize the Assessor (and their team) to provide additional reports should new information be required for review regarding the current claim.

I also consent that the Assessor’s assistant will be joining the assessment by way of teleconference for the primary purpose of note-taking. This evaluation will not be audio-taped or video-taped.

It is understood and agreed that this is an Independent Assessment only, and for this reason a therapeutic health practitioner and patient relationship will not be established, unless otherwise noted by the Assessor.

I also authorize the Assessor (and their team) to receive and review copies of all medical or non-medical records, as provided by the Third Party, that may be relevant to my claim and will assist in completing this assessment. A report detailing this assessment will be forwarded to the party that has retained the Assessor.

For Virtual Assessments:

I consent to this assessment being conducted via video and/or audio means. Assessment provided through video or audio communication cannot replace the need for an in person psychiatric assessment for certain disorders or urgent problems. If the Assessor is of the opinion that an in person assessment is required to formulate their opinion, then this will be requested.

 

We do our best to make sure that any information you give to us during virtual care assessments is private and secure, but no video or audio tools are ever completely secure. There is an increased security risk that your health information may be intercepted or disclosed to third parties when using video or audio communications tools. To help us keep your information safe and secure, you can do the following:

 

  • Understand that this method of communication is not secure in the same way as a private appointment in an exam room.
  • Use a private computer/device (i.e., not an employer’s or third party’s computer/device), with headphones and a secure internet connection. For example, using a personal computer or tablet is more secure than at a library, and your access to the Internet on your home network will generally be more secure than an open guest Wi-Fi connection. Headphones would help protect confidential conversations.

 

By providing your information, you agree to let us collect, use, or disclose your personal health information through video or audio communications (while following applicable privacy laws) in order to provide you with an assessment. In particular, the following means of electronic communication may be used such as (identify all that apply, such Zoom, OTN, Doxy, etc.).

 

Other tips for a successful virtual assessment experience: 1) Ensure your device has adequate power for at least two hours. 2) Assessments may not always commence on time due to unforeseeable circumstances. We will contact you by phone if a delay occurs. 3) Assessments may experience technological difficulties. We will contact you via phone if there is a problem. 4) Ensure your internet connection is stable. 5) Please be in a private room to ensure you can communicate in a confidential way. 6) The experience should mimic a visit to a doctor’s office.

You may revoke this consent at any time by contacting the Third Party or the Assessor.

Claimant’s Name



Claimant’s Signature

Date

Witness’s Name



Witness’s Signature

Date