IME consent:

IME Examinee Authorization for IME and Consent for Use and Disclosure of Protected Health Information

Please note: This page is for informational purposes only and may be updated from time to time. The language on this form is the same or similar as on the pdf-format consent form that will be provided to the examinee via secure e-mail for review and signature before the IME visit. There is no need to print out and sign this page.

01. General

I,__________________________________________________________________, DOB:____________________________, hereby give my consent for Bernhard Zunkeler, M.D., P.A., and Dr. Zünkeler to use my protected health information (PHI) to perform an Independent Medical Evaluation (IME). Depending on the jurisdiction or preferences of the party requesting the evaluation, an IME is sometimes referred to as “CME” (Comprehensive Medical Examination) or “AME” (Additional Medical Examination). These terms describe the same type of clinical assessment and are referred to in the document as “IME.”

An IME is different from a patient-physician treatment encounter. A regular patient treatment visit typically involves evaluation, treatment, payment, and health-care operations (TPO). The Bernhard Zunkeler, M.D., P.A., Notice of Privacy Practices explains how Bernhard Zunkeler, M.D., P.A., uses and discloses information obtained during such non-IME patient-physician visits.

02. What are the differences between an IME and a treatment-patient visit?

The main difference between an IME and a regular patient treatment visit is that the IME provider does not give any treatment advice to the IME examinee, so an IME is not a second-opinion visit. IME examinees are always asked to return to their treating providers. No continuity of care, consultation, surgical or other procedure, or medication prescription is offered by the IME provider. A traditional patient-physician treatment relationship therefore does not exist. Although Dr. Zünkeler may request x-rays to expedite the evaluation, it is understood that a traditional patient-physician treatment relationship will not be entered.

03. Who pays for an IME?

The IME requester (i.e. an insurance company, attorney, court of law, or another administrative entity) pays for the IME, including x-rays, if requested.

04. How do I obtain a copy of the IME report?

An IME examinee may request the IME report from his or her attorney or, if not represented by an attorney, from the party who requested the IME. In the event that the IME requester will not release the IME report to an unrepresented IME examinee, Bernhard Zunkeler, M.D., P.A., will release the IME report upon receipt of a written request and a self- addressed, letter-sized envelope with two Forever stamps. We do not release IME reports to anyone other than the IME requester or the IME examinee unless compelled to do so by subpoena or under other special circumstances as described in our Notice of Privacy Practices.

05. How is protected patient information processed differently in an IME versus a treatment-patient visit?

A treatment patient’s clinical note may be sent from the treating provider to another treating provider. Both providers are obligated to maintain patient information, which is protected under the HIPAA law and other laws as confidential. An IME is documented in an IME report, which is communicated between the IME provider and the IME requester, who is typically not a health-care provider.

Bernhard Zunkeler, M.D., P.A., sends an IME report to the IME requester by encrypted electronic transmission, facsimile, or U.S. mail and stores the IME report and associated records in paper or electronic files. Records are eventually destroyed. An IME report that has been sent to the IME requester may be distributed further without the knowledge or control of Bernhard Zunkeler, M.D., P.A.

Bernhard Zunkeler, M.D., P.A., strives to keep IME examinees’ and treatment patients’ health information confidential. We are continually refining our internal confidentiality and data security processes. Unintentional disclosures of privileged health information may occur, however, despite all efforts of the practice to protect examinee and patient privacy.

06. Telemedicine IMEs

A telemedicine IME (tele-IME) is convenient for the IME examinee because it can be conducted at home or another suitable location (i.e. the IME examinee does not have to travel to the IME provider’s office) and does not expose the IME examinee or provider to the risk of infection from an airborne virus (e.g. COVID-19 and influenza). However, the IME examinee must be physically present in Maryland at the time of the tele-IME. Before the tele-IME can proceed, the IME examinee must provide the same government-issued photo ID (e.g. driver’s license) used during the registration process.

The IME examinee’s full cooperation and preparation are necessary for a successful tele-IME. The IME examinee should select a safe, well-lit, and comfortable location; wear clothing that will allow the tele-IME provider to see body positioning (e.g. gym shorts and a T-shirt); and follow the instructions provided by Dr. Zünkeler’s office . If the IME examinee knows that he or she is physically unable to perform a maneuver requested by Dr. Zünkeler or knows that the maneuver will lead to increased pain, please tell Dr. Zünkeler (e.g. “I cannot do this”). To ensure safety, an adult who is physically able to assist the IME examinee in case of an emergency must be present during the exam portion of the tele-IME. The IME examinee may also choose one additional participant to remotely attend the tele-IME (e.g. an attorney) . Unless specifically agreed upon by BOTH the IME examinee and Dr. Zünkeler, no portion of the tele-IME may be audio- or video- recorded or archived by any participant, including the IME examinee’s remote observer.

Certain portions of the physical examination (e.g. deep tendon reflex examination) cannot be performed during a tele-IME, so the diagnostic accuracy of a tele-IME may therefore be limited compared with an in-office IME. The inability of the IME examinee to perform a critical portion of the examination or technical issues may make it necessary for the IME examinee to be examined in person by Dr. Zünkeler in his office at a later date to complete those portions of the tele-IME that could not be completed remotely.

07. Authorization for retrieval and review of online diagnostic radiology records

Diagnostic imaging studies (i.e. x-rays, MRI studies, CTs, and myelogram CTs) are often very important in neurosurgical, neurological, and musculoskeletal evaluations and in IMEs. Although Dr. Zünkeler has online access to some diagnostic imaging providers in Maryland, it is very helpful if IME examinees bring ALL diagnostic imaging studies on CDs (which will be returned) to the IME.

I give my consent for Bernhard Zunkeler, M.D., P.A., to review, if available, diagnostic images and reports contained in my online radiology record. I understand that I will not be charged for this service.

08. Authorization for Dr. Zünkeler to perform the IME

I hereby give my consent for Dr. Zünkeler to perform this IME. I understand that I may request the IME report from my attorney, if represented by an attorney; from the IME requester; or, if I am unable to obtain the report from either my attorney or the IME requester, from Bernhard Zunkeler, M.D., P.A. In the latter event, I will provide a written request and a self- addressed, letter-sized, and sufficiently stamped envelope. Except as necessary for identification purposes, no audio or video recording of the IME shall be made or stored by any IME participant unless expressly agreed upon by both Dr. Zünkeler and me.

09. Authorization to store and use photographs of me

In the event that Dr. Zünkeler and I both agree that photographs or videos of my body or part of my body would be helpful to better understand my medical condition, I give my permission for Dr. Zünkeler to store and use those photographs or videos to explain my condition by either including them in or attaching them to my IME report.

10. Examinee consent

I have read and understand the above. I provide my authorization for Dr. Zünkeler to perform this IME, to retrieve and review online diagnostic imaging studies, and to store and, only if agreed upon by both Dr. Zünkeler and me, use photographs or videos performed of me during the IME.

____________________________________________________________________________________ _____________________________________________________________________________________________

Patient signature (date) Witness signature (date)

rev: 04/28/2020