IME Consultation Registration & Consent

Step 1 of 3

Skype Video IME Consultation Registration & Consent
Name*
Date of Birth
Age:
Address:
Email*
Telephone contact: (mobile/home)
Employer:
Date of recruitment:
Date last at work:
Occupation:
GP name & address:
Specialists name & address:

Independent Medical Assessment:
An independent medical assessment has been requested by your insurance company in order to determine your suitability for insurance benefit. Your claim will be assessed according to the specific requirements of your policy. The assessment takes between 45 and 60 minutes and is a medical consultation. The doctor will ask you about your medical history and the impact of your illness on your daily life and ability to work. The doctor will also review medical reports submitted by your treating doctors. The doctor will issue a report on the findings of the assessment to the insurer. The doctor will not discuss the outcome of the assessment with you. A copy of the independent medical report is available from the insurance company under the terms of the Data Protection Acts.
Audio-visual Teleconference:
Independent medical assessment by telephone call /video-call (tele-consult) takes place when the claimant is unable to attend the Medwise clinic in person. The Medwise doctor will telephone / Skype / Zoom / Team call you at an agreed time. Please ensure that you have access to Skype, a microphone and a speaker. Please ensure that you can take the call in a private room without distractions or interruptions. Please have photo ID to show to the doctor.
Please complete the registration form and consent and return to Medwise by post or secure email one week prior to the consultation.
Teleconference Independent Medical Assessment Consent Form
1. Consent to tele-consult independent medical assessment and disclosure of medical details to the insurer:

By signing below, I consent to undergo a tele-consult independent medical assessment at Medwise at the request of my insurance company in order to process my claim for insurance benefit. I consent to allow disclosure of my medical information to the insurance company. I understand that no confidential medical details will be disclosed to any other third party.

2. Consent to Medwise retaining my personal health data: By signing below, I consent to Medwise retaining my personal health data as outlined and forwarding to The insurer for the purposes of processing your claim for insurance benefit.

The types of personal data, which we process for insurance health purposes, which are covered by the General Data Protection Regulations 2018, include name, residential address, data concerning health, medical information, insurance details, occupational information, birth date.

We will safeguard your personal data to ensure it remains confidential and will only handle your personal data in accordance with the terms contained in our Privacy Notice (available on request) and applicable data protection law.

We will retain your medical records on an ongoing basis, for as long as we have a relationship with you, and in order for us to: (a) comply with our legal records retention obligations; (b) inform a diagnosis of a latent condition, ensure your health and safety and protect your vital interests; (c) defend or bring legal claims; and/or (d) address complaints regarding our services.

We will delete your personal data once it is no longer required for these purposes. You may withdraw your consent at any time in which case we will delete your data unless we are otherwise permitted to keep your data for statutory or compliance.
1, 2 Signed:*
Date*
MM slash DD slash YYYY
Please provide the names and doses of your current Medication: (use overleaf if required)

MedWise occupational health physicians provide expert advice to HR, Health and Safety and Management.

Naas Clinic

Unit 32, Naas Town Centre,
Dublin Road, Naas,
Co. Kildare
W91 R230

Swords Clinic

First Floor, Chamber Building
North Street, Swords
Co. Dublin
K67 A3H7

IME Consultation Registration & Consent

Step 1 of 3

Skype Video IME Consultation Registration & Consent

Independent Medical Assessment:

Audio-visual Teleconference:

Teleconference Independent Medical Assessment Consent Form

Please answer the following lifestyle questions: