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 not a confidential evaluation.
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 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 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 understand and agree to the terms and conditions of the Acknowledgment of Limits to Confidentiality.
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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 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:
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I have viewed and agree to Electronic Delivery Informed Consent (Telemedicine Release)
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**Client Authorization Date:
Please provide the information requested above. Upon clicking submit, Weinstein & Associates, Inc. will receive email confirmation and add these authorizations to your file.
W&A Locations List
25700 Science Park Drive, Suite 200
Beachwood, Ohio 44122
P: 800.342.6111 | 216.831.1040
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