I, the consultee/undersigned (hereafter referred to as "Client"), the office of Dr. Zaky (hereafter referred to as "Office"), understand and agree to the following: I have been referred for a consultation by an agency (or self-referral) for the purpose of consultation, which may include diagnostic evaluation to assist DDD/QTC/VR/Court/FPL, or any other referral entity or on my directive. Limitations of Authority: I understand that Office does not have the authority to make the final determination (i.e., approval/denial) in cases of SSDI/ benefits or any benefits Client is applying for with any entity. Confidentiality: I understand that the information shared with the doctor or staff during the consultation will be relayed to the referring agency/entity in a report and not to Client (unless self-referral). Due to the nature of the consultation, no doctor-patient relationship would exist, and if Client wishes to obtain a copy of the consultation report or has question(s) about the consultation/report, Client and or their representative must contact the referring agency/entity directly. I agree that no report(s) or opinions will be shared by the doctor/staff directly with Client or their representative. Surveillance Cameras are used to deter crime and protect the safety and security of staff and Client. Surveillance cameras (in PSL office) are used upon walking into the building, conference rooms, and testing rooms. The cameras do not capture audio but rather video. Images obtained must be retained for a length of time, and they are NOT monitored by a monitoring company (only in the PSL office). Office do not have control over surveillance cameras used in satellite offices (e.g., WPB, BB, BG) used by Office. Unless such images have historical value or are being used for any investigation, their storage may be extended. Client agrees that no one is permitted to take pictures, audio/video recordings of tests, or interviews during the session without the written consent of this office, and only Dr. Zaky can authorize. Imminent Danger: I understand that if Dr. Zaky believes that there is imminent danger of Client's self-harming or harm to others, then the doctor/staff must act in informing the authorities/agencies/entities and pursue involuntary commitment/Baker Act to protect the claimant/others. Ownership and Use of Form and Content: I acknowledge that this form and its content are owned by Office, and it is not to be copied, photographed, or multiplied in any way. Communication: I (Client) authorize interactions/communication via phone calls, text, email, telehealth, letters, or any other means of communication for the purpose of confirming appointments, inquiries, or any other communication related to this consultation. I understand that your carrier may apply standard messaging and data rates and that Client is responsible for any fees associated with texts or other forms of communication by Client's phone carrier or any other fees. Cancelation/discontinuation of services: I (Client) understand that if I decide that I no longer wish to pursue releasing Client's report to the referring agency/entity, I must inform Office in writing and within a reasonable time before my scheduled appointment. If I fail to keep the confirmed appointment or wish to withdraw my participation or consent, Client is responsible for the total fees of the encounter, which may vary depending on the nature of the consultation and can range from several hundred dollars to thousands of dollars. HIPAA: I (Client) understand that Office must comply with the Health Insurance Portability and Accountability Act (HIPAA), a federal law that protects the privacy and security of personal health information. The office of Dr. Zaky is committed to protecting the privacy and security of my personal health information. I (Client) understand that Office will take appropriate measures to protect my personal health information from unauthorized access, disclosure, or use.
Telehealth: to ensure that you receive the care you need, our practice is offering telehealth services as an alternative to in-person visits. We want you to know that your privacy and security are our top priorities. Our telehealth platform complies with all applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). This means that we make efforts to keep your telehealth consultation private, secure, and confidential, just like an in-person visit. However, we cannot guarantee breaches. We recommend that you find a quiet, private space for your telehealth appointment to ensure the confidentiality of your medical information. Please also make sure to log in to your telehealth appointment from a secure device and network and log in 10 minutes before your scheduled appointment.