Neurology and Physical Therapy Centers of Tampa Bay

 2835 W. De Leon Street, Suite 205

Tampa, FL 33609

(813) 831-6622 / (813) 831-1218

FAX (813) 874-1936 

Notice to Examinee for Independent Medical Examination

We would like to inform you that you have been referred to our clinic for an INDEPENDENT MEDICAL EXAMINATION ONLY. This differs from other doctor visits you may have because this is an Independent Medical Examination regarding your injuries for your accident, and is usually accomplished in only one visit to our clinic. You will not be established as a patient at our practice. All treatment recommendations are to be followed through with your healthcare provider. If you do not have a healthcare provider, we urge you to seek one immediately.

What will you experience today:

The physician will listen to you carefully, take a detailed history and examine you. However, because this is an Independent Medical Examination, any diagnosis, treatment recommendations, medication prescriptions, referral to other healthcare providers or facilities for treatment, or any other treatment, care or other information regarding your medical treatment or condition will be your responsibility to follow through with, utilizing your current healthcare provider or another healthcare professional of your choice.

I have read and understand the above information, and I UNDERSTAND THAT THE PHYSICIAN, ROSANNA GARNER, M.D. or KIMBERLY TOBON, D.O., THAT IS PERFORMING MY INDEPENDENT MEDICAL EXAMINATION IS NOT MY TREATING PHYSICIAN.

I UNDERSTAND THAT I MUST THEREFORE SEEK TREATMENT OR CONTINUE TREATMENT WITH MY CURRENT HEALTHCARE PROVIDER, OR ANOTHER HEALTHCARE PROVIDER OF MY CHOICE, FOR ANY AND ALL MEDICAL NEEDS I MAY HAVE.

Neurology and Physical Therapy Centers of Tampa Bay

Vincent Di Carlo, M.D. & Associates, P.A.

2835 W. De Leon Street, Suite 205 Tampa, FL 33609
TEL (813) 831-6622
FAX (813) 874-1936

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND INFORMATION

1.      I authorize all health care providers, physicians, hospitals, medical staff and attorneys to furnish any and all information and medical records regarding me to Vincent Di Carlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay, including psychiatric, psychological and any mental health records.

 

2.      I authorize Vincent Di Carlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay to release any and all information and medical records regarding me, including psychiatric, psychological and any mental health records, to those parties that are necessary to process and/or collect from my insurance claim(s), and/or other claims related to my healthcare services.

 

3.      I authorize Vincent Di Carlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay to release any and all information and medical records regarding me, including psychiatric, psychological, and any mental health records to all healthcare providers involved in my care and their representatives, and to my attorney(s) and their representatives.

 

4.      I Agree that this authorization will cover all medical services rendered, with no limitations on dates and history of injury and/or illness, until such authorization is revoked by me in writing.

 

5.      I agree that a photocopy of this form may be used in lieu of the original.

Acknowledgement of Receipt of Notice of Privacy Practices for

Neurology and Physical Therapy Centers of Tampa Bay

 

By signing below, I acknowledge that I was given the Notice of Privacy Practices from Vincent Di Carlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay (on the website, or in the office) and I understand that I may request a paper copy to take with me if I would like one.