(Independent Medical Evaluation Company, Insurer, Lawyer, Employer, etc.), to conduct a thorough, unbiased independent psychiatric assessment of me, and to review the clinical notes and records provided, for the purpose of forming opinions to assist those adjudicating my claim. I understand and consent to the Assessor having remote administrative or clinical support via electronic communication, including through the use of technology tools, and that such individuals or systems may have access to my personal health information as required for the assessment and reporting process.
I authorize the Assessor to provide updated opinions should new information be provided at a later date.
I consent to the Assessor’s Assessment Administrator joining the assessment by teleconference, where applicable, to assist the Assessor. This evaluation will not be audio-recorded or video-recorded, except as may be required for real-time AI-assisted transcription in accordance with the technology consent provided in this form.
I understand that a therapeutic health practitioner–patient relationship will not be established, unless otherwise noted by the Assessor. While treatment recommendations may be included in the report, the assessment is conducted for independent medico-legal purposes. I agree to request that the Third Party provide a copy of the report to my treating clinicians, should treatment recommendations be made.
A report detailing the findings of this assessment will be forwarded to the Third Party via electronic communication. I acknowledge that despite reasonable efforts to protect privacy and security, electronic communication cannot be guaranteed to be completely secure, and I consent to the electronic transmission of the findings of this assessment.
I agree that the Assessor may retain copies of draft assessment notes and/or reports; however, requests for final reports should be directed to the Third Party.
I acknowledge and consent to PsycIME's use of secure technology tools, including software-assisted or artificial intelligence–supported systems, to assist with administrative, documentation, quality assurance, or report preparation processes. These tools are used as supportive aids only. PsycIME takes diligent steps to ensure that my personal health information will not be used to train or improve any AI models. All clinical opinions, conclusions, and final reports are reviewed, approved, and authored by the Assessor. I understand the specific purposes for which software-assisted or artificial intelligence–supported systems may be used, including but not limited to: transcription of assessment interviews, analysis of medical records, identification of relevant clinical information, drafting of report sections, and quality assurance checks. I understand that any AI-generated content will be verified by the Assessor before inclusion in the final report. I understand and consent to the possibility that my personal health information may be processed by AI systems on servers located outside of Canada, including in the United States. I understand that I have the right to request and receive information about the specific AI tools being used, how my information will be processed by these systems, where my data will be stored and processed (including whether it will be transferred outside of Canada) and the data retention policies for AI systems.
PsycIME selects and uses technology tools that are designed to comply with applicable privacy and data protection legislation, including PIPEDA, PHIPA, and, where applicable, HIPAA, and takes reasonable measures to protect the confidentiality and security of personal health information processed through these tools.
For Virtual Assessments:
I consent to this assessment being conducted via video and/or audio means. I confirm that I will be attending the assessment from the Canadian location I have disclosed to the Assessor, and that I will be attending alone unless otherwise agreed upon by the Assessor. I understand that a virtual assessment may not be appropriate for certain conditions or urgent matters, and that an in-person assessment may be requested if required to formulate an opinion.
PsycIME makes reasonable efforts to ensure that virtual assessments are conducted using secure platforms; however, no video or audio communication tools are completely secure. To help protect my privacy, I agree to attend the assessment using a private device (not an employer’s or third party’s device), a secure internet connection, and headphones where possible.
I acknowledge that, despite the use of encryption and security safeguards, electronic communications may inadvertently fail to be fully encrypted.
This consent may be revoked at any time by providing written notice to the Third Party or the Assessor.
