Exisiting Client.ALC.Shuman

Acknowledgment of Limits to Confidentiality
(Current Client)

The undersigned acknowledges understanding that the psychological evaluation to be conducted by Joshua Shuman, Psy.D.. on the Evaluation Date Listed below, is not a confidential evaluation. The results will be sent to the party who referred me for the evaluation. Whether or not you get a copy of the evaluation will be up to the party requesting the evaluation. That party might then release my report to all parties involved, including but not necessarily limited to the following:

The Ohio Bureau of Workers' Compensation
The Industrial Commission of Ohio
My attorney
My employer at the time of my injury
The attorney for my employer
The Managed Care Organization working on behalf of my employer

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I acknowledge that *

I understand and agree to the terms and conditions of the Acknowledgment of Limits to Confidentiality.

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 this 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: TELEMEDICINE RELEASE. Please contact us to ask questions and seek clarification of anything unclear to you.

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I have viewed and agree to Electronic Delivery Informed Consent (Telemedicine Release)

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**Client Signature Date:

Please provide the information requested above. Upon clicking submit, the evaluating psychologist will receive email confirmation. He/she will electronically sign and add these authorizations to your file.

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Acknowledgment of Limits to Confidentiality​(Current Client)

Acknowledgment of Informed Consent to Treatment via Electronic Service Delivery (Telemedicine Release)

Acknowledgment of Limits to Confidentiality
(Current Client)