therapeutic health practitioner and patient relationship will not be established ConsentSign
Informed Consent/ Disclosure for Independent Psychiatric Assessment/Release of Information




Claimant Identification Confirmed with ID:


I, the undersigned, provide consent to ‘the Assessor’, Dr. who has been retained by ‘the Third Party’ named (Independent Medical Evaluation Company, Insurer, Lawyer, Employer, etc.), to conduct a thorough unbiased independent psychiatric assessment of me, and review the provided clinical notes and records, in order to assist those adjudicating my claim. I understand the Assessor may have administrative support via electronic communication from their team who will also have access to my personal health information.

I authorize the Assessor to provide updated opinions should new information be provided at a later date.

I consent that the Assessor’s notetaking assistant will be joining the assessment by way of teleconference. This evaluation will not be audio-taped or video-taped.

A therapeutic health practitioner and patient relationship will not be established, unless otherwise noted by the Assessor. However, this assessor’s assessment and report may yield treatment recommendations. In this instance, the undersigned agrees to request the third party to provide a copy of the report to your treating clinicians for consideration in preventing disease, maintaining health, and assisting with coping with and treating, both illness and disability.

A report detailing this assessment will be forwarded to the Third Party via electronic communication that has retained the Assessor.

Despite reasonable efforts to protect the privacy and security during electronic communication, it is not possible to completely secure the information shared via e-communication.

I agree that the Assessor may retain a copy of assessment notes and/or the final report, but I would ask that my other medical records be destroyed once the assessment and report is completed, as the Assessor is not my treating provider and should have no further use for my medical records.

For Virtual Assessments:

I consent to this assessment being conducted via video and/or audio means. I confirm that I will be attending this assessment alone, unless the Assessor and I agree to an additional member joining the assesment. An assessment provided through video or audio communication cannot replace the need for an in person psychiatric assessment for certain disorders or urgent problems. If the Assessor is of the opinion that an in person assessment is required to formulate their opinion, then this will be requested.

We do our best to ensure that information provided during a virtual assessment is private and secure, but no video or audio tools are ever completely secure. To help keep your information safe and secure, please use a private computer/device (i.e., not an employer’s or third party’s computer/device), with headphones and a secure internet connection.

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications regarding my case may inadvertently fail to be fully encrypted.

You may revoke this consent at any time by providing written direction to the Third Party or the Assessor.

Claimant’s Name

Claimant’s Signature