I understand that I am here for an independent medical examination (IME), which means the doctors(s) performing the evaluation is neither treating me nor an employee of whomever requested the IME (insurance company, third party administrator, attorney, governmental agency, employer, or physician). I understand the purpose of the independent medical examination is to provide a thorough, objective evaluation of the specific condition(s) related to my injury or illness which is in question, as well as prior subsequent conditions that might affect it, and to answer whatever questions the requesting party has. This sheet outlines the process, my rights, and my responsibilities.
This IME is not a comprehensive medical examination. I understand it will not provide advice or treatment to me or substitute for evaluation or treatment by my regular treating doctor. I understand a patient/physician relationship is not established between the evaluating physician and me. Accordingly, there is no patient/physician privilege associated with this evaluation. Usually a written report will be prepared summarizing today's evaluation and sent to the requesting party.
If I would like a copy of the report, I will contact them.
I understand that generally the evaluation will begin with the doctor obtaining a history of how my problem began and what evaluation or treatment has been rendered since. Utilizing information I provide verbally and on the history forms, as well as that contained within whatever records may be available for review. The doctor well then ask about my current symptoms and record a relatively brief past medical and other information such as my work status, etc. All information which I provide may be included in the report.
After the interview, a physical examination of the relevant body part(s) will be conducted. I understand that I need not perform any maneuver I feel might cause injury or a worsening of my symptoms, and will immediately inform the examiner if anything he is doing is causing excessive discomfort so it can be stopped right away. Some pain, stiffness, or other symptoms are produced in most physical examinations of this sort. For instance, when touching a tender spot or checking how far a stiff joint can move, and such findings are helpful in understanding the condition. The IME, however, is not intended to cause injury or excessive pain. I understand that in order to avoid that I must fulfill my responsibility to inform the doctor(s) if there is something I can't do, a certain test is causing too much discomfort, etc.
I also understand that I will be permitted to have a family member or friend, who is not a licensed clinical practitioner, present during the physical examination . It may be necessary to obtain additional x-rays or other diagnostic tests in order to answer certain question. These may be performed here or at another facility.
I have read and understand the aforementioned information and instructions . I authorize this physician or any co-examiner to obtain any information that may be of relevance to the condition(s) in question, and to release that information and the results of the IME (verbally or in writing) to any entity who has requested the IME.
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