Consent for Independent Medical Assessment

Consent for Independent Medical Assessment

INFORMATION ABOUT COMPLETING THIS CONSENT FORM


Referral to Case Management


You have been referred to Cognate Health Ltd for an assessment of your health in relation to your employment. Your Manager/Human Resources Advisor should have discussed the reason for your referral with you. If you are not clear about the reason for the referral you should discuss the matter with your manager or your Human Resources Advisor before your consultation.


The Independent Medical Consultation


The purpose of the consultation is:

  1. To assess your fitness for work.
  2. To assess whether you would require any adjustments to your work in accordance with the Employment Equality Act.
  3. To assess which parts of your job you are able to do and what reasonable adjustments may be advised to enable you to work.
  4. To ensure your health and safety at work.

During the consultation a doctor will make an assessment of your current clinical condition and take details of any relevant past history. This may include a physical examination. The examination findings will form the basis of a report to review the extent of any incapacity or disability and its effect on your activities of daily living, as well as any impact on your fitness for work. The doctor may also discuss any adjustments that may assist you in the workplace.

Following the assessment, the occupational health physician may require further information from your GP or specialist. If you agree to the occupational health physician approaching your doctor for a report, you will be asked to sign a separate consent form.


The Occupational Physician Report


Once all the necessary information is gathered, a written report will be sent to Cognate Health Head Office where it will be quality checked before being sent to your employer. The report will outline the effect your medical condition has on your ability to work. Only relevant information will be disclosed to your employer. This may include relevant medical information.

The report will:

  1. Advise on your capacity to work.
  2. Make recommendations on workplace adjustments if necessary.

If you have significant health problems, you may be restricted from undertaking some or all of the duties required of your post. If this is the case a statement will be made of suitable alternative tasks you could undertake and for how long.

The doctor will discuss what the content of the report will be during your consultation, including the recommendations to be made.

The doctor will send the report to Cognate Health Head Office for Quality Control before being forwarded to your employer.


Refusal of Consent


You can refuse to be assessed however it is important that you understand that without your consent we are unable to give any advice on your condition to your employer. Please be aware that this may ultimately have a bearing on the management of your case.

I have read and understood the reason for the occupational health physician assessment.

I consent to:

Being assessed by one of Cognate Health’s Network doctors for the purpose of assessing my current medical condition and any impact this may have on my ability to work and Cognate Heath sending a report to my employer.

In signing this form, you confirm your explicit consent within the meaning of The Data Protection Act for the Occupational Health Service Provider to process and store your personal information.

Cognate Health is a trusted company governed by an ethic of privacy and confidentiality. In order to provide for your care, we need to collect and keep information about you and your health in your medical record. Our policies are consistent with General Data Protection Regulation (GDPR) and Medical Council guidelines and the privacy principles of the Data Protection Regulations. This practice has voluntarily adopted the requirements of General Data Protection Regulation (GDPR).

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