Acknowledgment of Limits to Confidentiality

    I, the undersigned Injured Worker, acknowledges understanding that the psychological evaluation to be conducted by a psychologist with Weinstein & Associates, Inc. is considered confidential evaluation by Weinstein & Associates. However, this evaluation will produce a report that will be sent to the referring party only, who is considered the client, who will then release the report to whomever that party deems appropriate. The undersigned acknowledges that the purpose of the evaluation is to determine psychological status relative to the work injury. The Injured Worker further acknowledges that this evaluation will be conducted via Telemedicine. This evaluator utilizes the HIPAA compliant telemedicine platform, Doxy.me.
     
    The undersigned also is aware that he/she is not a client of Weinstein & Associates, Inc., that Weinstein & Associates, Inc. is not responsible for his/her mental health care and that the evaluation in no way implies that the Injured Worker is receiving treatment for any mental health issues from Weinstein & Associates, Inc. The Injured Worker further acknowledges understanding that at a future point in time, should he/she begin a counseling relationship with Weinstein & Associates, Inc., he/she would become a client of Weinstein & Associates, Inc. which would then be responsible for his/her mental health care and would provide ongoing treatment for those mental health issues. In that relationship, the client would hold all confidentiality rights, as set forth in a separate Informed Consent form as well as in a HIPAA Notice of Privacy Practices form.
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    Acknowledgment of Informed Consent to Treatment via Electronic Service Delivery (Telemedicine Release)

    Acknowledgment of Informed Consent to Treatment via Electronic Service Delivery means you voluntarily agree to receive mental health assessment, care, treatment, or services and authorize your  evaluator to provide such care, treatment or services as are considered necessary and advisable via electronic service delivery means. By signing this Electronic Service Delivery Informed Consent, you, the undersigned client, acknowledge that you have both read and understood all the terms and information contained herein and you agree to be bound by the provisions in this agreement. The entire Telemedicine Release is available to view or download here and applies to this service:​  TELEMEDICINE RELEASE.  Please contact us to ask questions and seek clarification of anything unclear to you.  ​
    Please provide the information requested above.  Upon clicking submit, Weinstein & Associates, Inc. will receive email confirmation and add these authorizations to your file.