{"content":[{"text":"!","bbox":{"left":0.507516,"top":0.184398,"width":0.004318000000000044,"height":0.017763}},{"text":"Informed Consent to Neuropsychological Section 312 Exam","bbox":{"left":0.253887,"top":0.249374,"width":0.4963620000000001,"height":0.017045000000000005}},{"text":"Neuropsychological Exam \n Neuropsychological examination will include an interview, record review (for example, of medical, psychiatric, \n substance use, social, educational, legal, and occupational history, as relevant and available), and testing with a variety \n of different measures, none of which are medically invasive (e.g., no needles). The purpose of the evaluation is to \n provide objective information about your brain functioning in a variety of areas including, attention, concentration, \n motivation, fine motor and sensory abilities, language and visuospatial skills, executive skills (e.g., problem solving and \n organization), memory, intellectual functioning, and emotional or personality functioning.","bbox":{"left":0.03001,"top":0.283313,"width":0.8954850000000001,"height":0.11946899999999999}},{"text":"This examination is not treatment. You may feel better or worse after your appointment(s). Although it would not be \n expected to occur, you should tell us if any of the procedures cause you any discomfort, and upon that information, \n we will discuss terminating or altering the procedure. It is important that you try to do your best on all of the tests so \n that the test results accurately reflect your abilities. Validity across the testing process is measured and must be \n reported along with other results. Your participation in the evaluation is voluntary, so you can end the evaluation at \n any time that you choose.","bbox":{"left":0.03001,"top":0.419677,"width":0.88834,"height":0.10219600000000001}},{"text":"You will be given short breaks as needed and a lunch break if you are here for a full day.","bbox":{"left":0.03001,"top":0.539071,"width":0.6686340000000001,"height":0.017044999999999977}},{"text":"Professional Fees: The evaluation is paid for by the State of Maine Workers’ Compensation Board","bbox":{"left":0.03001,"top":0.57301,"width":0.757474,"height":0.017044999999999977}},{"text":"Cancelation for Illness/Injury: If you are significantly ill or have been recently injured in such a way that you are \n not sure that you are able to or should keep your appointment, call us immediately.","bbox":{"left":0.03001,"top":0.607252,"width":0.869592,"height":0.03401500000000002}},{"text":"Limits on Confidentiality \n • Your examination has been requested as a Section 312 Exam by the State of Maine Workers’ Compensation \n Board. As such, the conditions of this examination do not create or involve a doctor-patient relationship. The \n full results of the examination will be sent directly to the State of Maine Workers’ Compensation Board. \n • If an examinee were to file a lawsuit or a complaint against NCMA or one of our neuropsychologists or staff \n members, we may disclose relevant information about that examinee to respond to the complaint or lawsuit. \n (This has never happened in our practice) \n There are some circumstances under which we are is legally obligated to take actions in order to attempt to protect \n people from harm, and in carrying out those actions, some of a examinee’s personal health information could be \n disclosed. These situations are very unusual in our experience. \n • If we know or have reasonable cause to suspect that a child under the age of 18 has been or is likely to be \n abused or neglected or that a vulnerable adult has been abused, neglected or exploited and is incapacitated or","bbox":{"left":0.03001,"top":0.658465,"width":0.89018,"height":0.21098400000000006}},{"text":"!","bbox":{"left":0.902436,"top":0.940459,"width":0.004318000000000044,"height":0.017762999999999973}}],"images_bbox":[{"left":0.073931,"top":0.045765,"width":0.863584,"height":0.137879},{"left":0.101504,"top":0.898416,"width":0.800437,"height":0.056439}],"images_bbox_not_text_overlap":[{"left":0.073931,"top":0.045765,"width":0.863584,"height":0.137879},{"left":0.101504,"top":0.898416,"width":0.800437,"height":0.056439}]}