Independent Medical Evaluation Questionnaire Form

I am attending and agree to a virtual based Independent Medical Examination. There is no treating relationship being established with the assessor. In the event there are clinical findings that require attention the assessor will make recommendations to follow-up with the treating physician so that appropriate care is undertaken. I understand that a written report will be prepared and sent to the referring source. I understand that I can decline any task that I feel I cannot do and will inform the assessor. I understand and agree that I will not record this examination in any way. I understand that a piece of photo I.D. may be request and documented by the assessor. Health Records and information related to this assessment, as provided by the referral source and/or by me or my representative may be accessed by the administrative personnel or the Assessor, for the strict purposes of processing the referral and service delivery management. All records will be maintained in such a manner as to protect the confidentiality of the information to the fullest extent possible, meeting all PIPEDA privacy and confidentiality regulations. File material is retained based on the regulations outlined by the College of Physicians and Surgeons of Ontario, British Columbia, Alberta, Nova Scotia and New Brunswick. This file material is also is retained in accordance with the College of Psychologists of Ontario and PIPEDA.