Virtual Consultation

Remote Second Opinion Consent Form

I have requested Cincinnati Cancer Advisors to arrange a medical second opinion for me regarding the condition described below with a physician affiliated with Cincinnati Cancer Advisors (“CCA”). Following that consult, CCA will deliver to me and to my designated physician a written report (the "Report") reflecting the conclusions of the CCA physician and will discuss the conclusions with me and my designated physician. The CCA physician will reach those conclusions based solely on the information provided by me or my health care providers. CCA shall not have any liability or responsibility for the accuracy or completeness of that information or for any errors in its transmission. 

 

I understand that CCA is a consultation-only service and does not provide direct treatment. By providing the Report, CCA does not assume any continuing responsibility for my medical care or treatment. In addition, I recognize that, without a complete in-person physical examination, the CCA Physician will be limited in his or her ability to correctly assess or diagnose my condition and recommend treatment.
 

Although CCA has no obligation to obtain additional medical records or other information regarding my condition, I authorize my designated physician and any other person or entity to release any information pertaining to my health including health history, present complaints and laboratory and diagnostic data to CCA. CCA is authorized, at its election, to obtain any of such records and information. 

 

For myself and my heirs, personal representatives, administrators, successors and assigns, I irrevocably release CCA and their trustees, officers, and employees from any and all known or unknown, foreseen or unforeseen, claims, actions or damages arising in connection with the consultation or the information contained in the Report.

Patient Information

Designated Physician Identification

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