Acknowledgment of Limits to Confidentiality
    ​(Existing Client)

    I, the undersigned Injured Worker, acknowledges understanding that the psychological evaluation to be conducted by a psychologist with Weinstein & Associates, Inc. is  considered a confidential evaluation by Weinstein and Associates. 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. Although considered confidential by Weinstein and Associates, the results will be sent to the party who referred me for the evaluation and I understand that person or party is considered our client, not me. Whether or not I 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:

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    • 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 

    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, 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.