Authorization for Comprehensive Medicolegal Evaluation/Life Care Plan Evaluation 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 LCP evaluation. There is no need to print out and sign this page.
I, _______________________________________________ DOB :_____________ , hereby request and give my consent for Bernhard Zunkeler, M.D., P.A., and Dr. Zünkeler, a board-certified neurosurgeon and certified life care planner (CLCP), to use my protected health information (PHI) to perform a comprehensive medicolegal evaluation/life care plan evaluation (LCP evaluation) for the purpose of creating a comprehensive evaluation and life care plan report (LCP evaluation report). I understand that no patient-physician relationship is intended by this LCP evaluation. I understand that reasonable and full effort is expected of me during the evaluation and that I am to notify Dr. Zünkeler if this is not possible.
An LCP evaluation is different from a regular patient-physician treatment encounter and is not intended to provide medical care or to represent the practice of medicine, as is explained in detail below. A regular patient treatment visit typically involves 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 regular patient treatment visits.
02. What are the differences between a comprehensive medicolegal evaluation/life care plan evaluation and a regular patient treatment visit?
Dr. Zünkeler feels that the differences between the LCP evaluation that you are agreeing to in this document and a regular patient treatment visit are important for you, the “LCP evaluation examinee,” to understand. Because of these differences and to avoid any confusion, you will be referred to as the “examinee” rather than the “patient.”
i) What an LCP evaluation is not: In an LCP evaluation, Dr. Zünkeler does not intend to treat or advise the examinee, perform a medical consultation, or provide prescriptions or diagnostic services. An LCP evaluation is a form of case management and is not intended to represent or replace the practice of medicine. Examinees are always encouraged to continue seeing their treating providers. Although Dr. Zünkeler may meet with the examinee on more than one occasion (either in person or via televideo conferencing) and perform one or several interviews and examinations, no consultation, continuity of care, diagnostic services, surgical or other procedures, or medication prescriptions will be offered.
ii) What an LCP evaluation tries to accomplish: In his role as a physician life care planner, Dr. Zünkeler will review the available medical records and diagnostic imaging studies and generate a summary of records. Dr. Zünkeler will consider the diagnoses, medical opinions, and treatment recommendations already established and documented by the examinee’s treating medical providers. Dr. Zünkeler will then conduct a systematic LCP evaluation interview and LCP evaluation examination to confirm the existing diagnoses and treatment recommendations and to establish the central opinions of the LCP evaluation. These central opinions will then form the basis for Dr. Zunkeler’s conclusions regarding future medical requirements, cost analysis, and cost/vendor survey and will guide him in conducting a review of the medical literature and which references and exhibits to select for inclusion in the LCP evaluation report. An LCP evaluation report is a “dynamic document,” which means that it may need to be updated periodically.
With the permission of the examinee, Dr. Zünkeler may contact the examinee’s treating physicians regarding thoughts, insights, and predictions regarding future medical needs.
03. Payment for the LCP evaluation
I understand that financial arrangements for this evaluation have been made between the office of Dr. Zünkeler and the referring office for this evaluation. The cost of Dr. Zünkeler’s services as a medical expert and certified life care planner will not be billed through health insurance or subject to any type of health insurance contract.
04. Electronic health record
I understand that Dr. Zünkeler and his designated personnel may use an electronic health record and electronic means (including telephone, televideo systems, and e-mail) to communicate with me, my legal representative, and my medical providers. I authorize Dr. Zünkeler to participate in a health information exchange (HIE) and/or electronically share my health information or that of my minor child or dependent with other providers to serve medical care needs, in addition to exchanging messages via e-mail. I further understand that health information will remain protected as required by law and as further explained below.
Bernhard Zunkeler, M.D., P.A., strives to keep LCP evaluation 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.
05. Notice of Privacy Practices
I acknowledge that the office of Dr. Zünkeler maintains Notice of Privacy Practices and that I have had the opportunity to review and/or receive a copy of these practices.
06. How is protected patient information processed differently in an LCP evaluation versus a regular patient treatment visit?
A patient’s clinical note may be sent from the treating provider to another treating provider. Both providers are obligated to maintain patient information as confidential under the HIPAA law and other laws. An LCP evaluation is documented in an LCP evaluation report, which is communicated between the LCP evaluation provider and the LCP evaluation requester, who is typically not a health-care provider. An LCP evaluation report is a dynamic document, so an original LCP evaluation report may be supplemented (usually as an LCP evaluation addendum report) as new information becomes available.
Bernhard Zunkeler, M.D., P.A., sends an LCP evaluation report to the LCP evaluation requester by encrypted electronic transmission, facsimile, or U.S. mail and stores the LCP evaluation report and associated records in paper or electronic files. Records are eventually destroyed in accordance with § 4-403 (b-c) of the Annotated Code of Maryland:
(b) Except for a minor patient, unless a patient is notified, a health care provider may not destroy a medical record or laboratory or X-ray report about a patient for 5 years after the record or report is made.
(c) In the case of a minor patient, a medical record or laboratory or X-ray report about a minor patient may not be destroyed until the patient attains the age of majority plus 3 years or for 5 years after the record or report is made, whichever is later….
Please note that an LCP evaluation report that has been sent to the LCP evaluation requester may be distributed further without the knowledge or control of Bernhard Zunkeler, M.D., P.A.
07. Communication with other medical providers
On occasion, Dr. Zünkeler may communicate with other medical providers (by telephone or other form) regarding your condition, diagnosis, prognosis, or future medical needs. If this is unacceptable, please indicate below.
Health information disclosure restrictions:
☐ I have no disclosure restrictions.
☐ I have the following communication restrictions: _____________________________________________
08. Televideo LCP evaluations
A televideo LCP (tele-LCP) evaluation can be conducted from the examinee’s home, an acute-care or long-term rehabilitation facility (after institutional approval has been obtained), or the office of the examinee’s legal representative.
The examinee, representative, or guardian should select a safe, well-lit, and comfortable location. The examinee should wear clothing that will allow Dr. Zünkeler to see body positioning (e.g. gym shorts and a T-shirt) and follow the tele-LCP preparation instructions provided by Dr. Zünkeler’s office. If the examinee knows that a maneuver requested by Dr. Zünkeler is not physically possible or knows that the maneuver will lead to increased pain, the examinee should tell Dr. Zünkeler (e.g. “I cannot do this.”). To ensure safety, an adult who is physically able to assist the examinee in case of emergency must be present during the exam portion of the tele-LCP evaluation. The examinee may also select one or two additional participants to remotely attend the tele-LCP evaluation (e.g. a legal representative or a family member). Unless specifically agreed upon by BOTH the examinee and Dr. Zünkeler, no portion of the tele-LCP evaluation may be audio- or video-recorded or archived by any participant, including the examinee’s remote observer(s).
Certain portions of a physical examination (e.g. deep tendon reflex examination) cannot be performed during a tele-LCP evaluation, so the examination accuracy may be limited compared with an in-person LCP evaluation. The inability of the examinee to participate in the entire initial interview portion of the LCP evaluation (which can be lengthy, i.e. up to 2 hours) or to perform a critical portion of the examination (e.g. because of fatigue) or technical issues may make it necessary for the tele-LCP evaluation to be continued at a later date or in person at the examinee’s home or other location.
09. 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 LCP evaluations. Although Dr. Zünkeler has online access to some diagnostic imaging providers in Maryland, it is very helpful if the examinee or legal representative provides ALL diagnostic imaging studies on CDs (which will be returned) well before the LCP evaluation.
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.
10. Authorization for Dr. Zünkeler to perform the LCP evaluation
I hereby give my consent for Dr. Zünkeler to perform this LCP evaluation. I understand that I am encouraged to promptly review the LCP evaluation report personally and to notify Dr. Zünkeler of any errors or misunderstanding. I understand that I may request the LCP evaluation report from my attorney or from the LCP evaluation requester. If I am unable to obtain the report from either my attorney or the LCP evaluation requester, I may request in writing the report from Bernhard Zunkeler, M.D., P.A. No audio or video recording of the LCP evaluation will be made or stored by any LCP evaluation participant unless expressly agreed upon by Dr. Zünkeler and me.
11. 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 LCP evaluation report.
12. Examinee consent
I have read and understand the above. I provide my authorization for Dr. Zünkeler to perform this LCP evaluation and 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.
Authorized signature (date) Witness signature (date)