Neurology and Physical Therapy Centers of Tampa Bay

2835 W. De Leon Street, Suite 205, Tampa, FL 33609

(813) 831-6622 - (813) 873-1218

FAX:  (813) 874-1936

We would like to inform you that you that you have been referred to our clinic for a COMPULSORY PSYCHOLOGICAL EVALUATION ONLY scheduled by a third party. This differs from other visits you may have because this is a COMPULSORY PSYCHOLOGICAL EVALUATION, and is usually accomplished in only one visit to include an initial interview with the psychologist. Following this initial interview, psychological testing will be administered either remotely or in the office.

What you will experience today: The psychologist will listen to you carefully. She will take a detailed history. Psychological testing will be performed. However, because this evaluation was arranged by a third party, she will not be able to provide you with a diagnosis, treatment recommendations, or any other information regarding your psychological treatment or condition.

Also, because this evaluation was arranged by a third party, she will not be providing you with a copy of your results of your evaluation and/or any testing performed as part of your evaluation. Results and evaluations are sent to the third party requesting the compulsory psychological evaluation. Please contact the third party that scheduled your appointment with us if you have any questions regarding requesting a copy of any information obtained from this evaluation, or if you have any other questions regarding the evaluation.

I have read and understand the above information, and I UNDERSTAND THAT THE PSYCHOLOGIST, DR. SHELLEY TINDELL, PSY.D., THAT IS PERFORMING MY COMPULSORY PSYCHOLOGICAL EVALUATION IS NOT MY TREATING PSYCHOLOGIST.

I UNDERSTAND THAT I MUST THEREFORE SEEK TREATMENT OR CONTINUE TREATMENT AT ANOTHER FACILITY FROM ANOTHER PSYCHOLOGIST OF MY CHOICE, FOR ANY AND ALL PSYCHOLOGICAL NEEDS I MAY HAVE.

AUTHORIZATION FOR RELEASE OF AND OBTAINING PSYCHOLOGICAL, PSYCHIATRIC AND SUBSTANCE ABUSE RECORDS

 

I authorize the physicians, hospitals, medical attendants and attorneys involved in my care to furnish all and complete medical reports, records and information regarding me to Vincent Di Carlo, M.D., and Associates, PA., d/b/a Neurology and Physical Therapy Centers of Tampa Bay, including psychiatric, psychological, mental health records, and any alcohol, drug or substance abuse records.  Additional individuals are included as listed:  _________________________________________________________________________.

 

I authorize Vincent DiCarlo, M.D. and Associates, P.A., d/b/a/ Neurology and Physical Therapy Centers of Tampa Bay to release any information necessary to process my insurance claim(s), including psychiatric, psychological, mental health records, and any alcohol, drug or substance abuse records. 

 

I authorize Vincent Di Carlo, M.D. and Associates, P.A., d/b/a Neurology and Physical Therapy Centers of Tampa Bay to release medical information, including psychiatric, psychological, mental health records, and any alcohol, drug or substance abuse records, to my health care providers, my attorney or my attorney’s representative, and in response to a subpoena or court order requesting such information.

 

I authorize Vincent Di Carlo, M.D., and Associates, P.A., d/b/a Neurology and Physical Therapy Centers of Tampa Bay to release medical information, including psychiatric, psychological, mental health records, and any alcohol, drug or substance abuse records to:  ___________________________________________________________________________________________________________.

 

I agree that this authorization will cover all medical, psychiatric, psychological services rendered, and any alcohol, drug or substance abuse records with no limitations on dates and history of injury and/or illness,  until such authorization is revoked by me in writing.  I understand that I may revoke this consent at any time except to the extent that action based on this consent has already been taken. 

 

I hereby release Dr. Shelley Tindell-Nodine, Psy.D., and Vincent Di Carlo, M.D., and Associates, P.A., d/b/a Neurology and Physical Therapy Centers of Tampa Bay, their employees, agents, and representatives from all legal responsibility that may arise from the release of the above requested information.  This authorization is fully understood and is made voluntarily and with informed consent on my part.  I agree that a photocopy of this form may be used in lieu of the original.