The information that you enter on this intake form goes to a secure server where the information is stored. While not HIPAA certified (there are plans to seek certification), the server does comply with the technical safeguard section of the HIPAA security rule. For example, the server has passed Level 2 PCI certification, which is high level security requirement necessary to protect private information. The servers SSL certificates support high-grade 256-bit encryption. However, as with any information passed through the internet, there can be risks.

In an effort to further reduce the possibility of identity theft you will not be entering your name, address, phone number, or other clear identifying information. Instead, you will only enter the date of your appointment with Dr. Kinsora and the age of the examinee.

Since the intake questionnaire is not yet HIPAA certified, you must agree to use this online intake and be okay with the fact that it is not HIPAA certified yet. This online intake is being offered as a convenient option to the hand written form. If you decide that you would rather have the hand written form, please contact our office at 702 382-3670. We would be happy to send you a copy to fill out by hand.

LIMITS TO CONFIDENTIALITY
The assessment that you have been referred for may be more detailed and comprehensive than any evaluation that you have experienced. It will take an entire day, but most people find it fun and challenging. The results tell us about how well your brain is functioning. This is very important to doctors and others who need to know how a particular medical condition or injury has affected you. The final results of this evaluation are based on this intake questionnaire, available records, and on your performance on the scheduled neurocognitive examination.

The final results will be forwarded to the party who requested the assessment. In most cases this will be your doctor. However, if the evaluation is related to a workers compensation claim or disability claim, your results will go directly to the insurers involved in your claim. If the evaluation involves a lawsuit, attorneys on both sides of the case will typically have access to the results of this examination. According to state law, under the following conditions, confidential information can be divulged without anyone's permission, whatsoever:

1. When disclosing the information “is necessary to protect against a clear and substantial risk of imminent serious harm by the patient to the patient or another person....”. NAC 641.224
2. When ordered to disclose information by a legal authority such as a judge or court administrator.
3. When required by law, such as when there is reasonable suspicion of abuse to a child or vulnerable adult.
4. If you are involved in litigation and the information obtained as part of the assessment is deemed to be a necessary part of the litigation, or when the assessment itself is part of the litigation procedure.

The tests that we administer are related to cognitive skills, and also psychological functioning. The examinee may be asked to do things such as remember stories, put together blocks to make designs, hold numbers in one's mind, and respond rapidly to letters on a computer screen. We may test the examinee's ability to solve conceptual problems, and may test the ability to answer questions about the world. On some tasks the examinee may need to go as fast as they can, and on others they are only required to be as accurate as possible. We may measure finger-tapping speed, fine motor skills, and grip strength. May test sense of smell. We may ask about anxiety, depression and other emotional symptoms. Most tests are only 2 to 5 minutes long, but there are a lot of them to complete during the day that you are with us. We will give breaks and the examinee is welcome to take snacks.

Foreseeable Risks, Discomforts, and Benefits: The vast majority of examinees find the assessment challenging, and intriguing. Some call the test that we administer "fun". Either way the tests can be challenging. Rarely, neuropsychological examinations can cause temporary fatigue, frustration, and anxiety. We will try to make this an enjoyable experience, nonetheless.

ILLNESS: If the examinee wakes up on the day of the examination and is clearly ill, or you know that the examinee is ill in the days before the exam, please do not come in. Call us immediately (702 382-3670) and let us know that and we will reschedule you as soon as we can over the coming weeks.

RULES: - Below are some important rules that we have for you to follow.

Rule 1: Be honest and forthright when answering the questions below: Some of the questions on this intake are highly personal. However, research clearly tells us that we are complex beings that are affected by our life experiences, our educational history, our social history, and our medical history. This is why people heal at different rates from injuries, and react in different ways to trauma. We can understand the examinee best when we understand the overall system from which they came and the system in which they live presently. For this reason, it is important to be as honest and up front as possible when completing this questionnaire.

Rule 2: RECORDING AND TAKING NOTES ARE STRICTLY FORBIDDEN. We are required by law to protect the security of the tests that we administer (Nevada Administrative Code 641.234). Our ethical guidelines also demand that we make every attempt to protect the test material from release to anyone not licensed to possess them. In an effort to keep our legal and ethical obligations, and preserve the validity of the measures, we strictly forbid any type of recording (audio, video, photography, live feed, across cellular or other transmission device, and others), direct or indirect observation, and any type of note-taking during the assessment day.

Rule 3: Absolutely no one other than the examinee, Dr. Kinsora, and Dr. Kinsora's staff members are allowed in the room during the evaluation.