Informed Consent Form
Centre for Medical Expertise – Linus Pauling Prevention Center Dr Werner Faché
1. Purpose of the medical expertise
I, the undersigned, ………………………………………………………….., declare that I have been informed in a clear and understandable manner about the nature, purpose, course and limitations of the requested independent medical file expertise.
I understand that this concerns an independent, integrated assessment of my medical file, with the aim of analysing the available information again as a whole and formulating a scientifically substantiated opinion (second/third opinion or integrated file analysis).
This expertise carries no guarantee of a new diagnosis, treatment or solution. It constitutes an obligation of means to carry out a thorough and independent analysis.
In this context, the Centre for Medical Expertise does not act as a court-appointed expert and does not accept any judicial expert assignment through this engagement.
2. Procedure
The process generally comprises an assessment of the suitability of the file, a preparatory analysis of the available medical data, an extensive personal consultation whose duration is determined by the nature and complexity of the file and, where appropriate given the nature of the file, a written and reasoned medical opinion.
With my explicit consent, and where relevant, consultation may take place with my general practitioner, specialist, radiologist or another qualified care provider.
3. Independent and advisory character
I understand that this expertise does not replace my treating general practitioner or specialist. Diagnostic and therapeutic decisions and further medical follow-up continue to take place within the existing doctor-patient relationship.
The expertise may contain diagnostic or therapeutic recommendations, but does not in itself entail taking over the treatment or providing long-term medical follow-up.
Any digital analysis methods serve a purely supporting function; the final medical judgement rests on the personal and independent clinical assessment of Dr Werner Faché.
4. Cost
The base fee amounts to € 600 and covers the initial thorough analysis of the file, the preparation, the extensive consultation and, where appropriate given the nature of the file, a written and reasoned medical opinion.
The fee is paid before the substantive analysis of the file begins. For exceptionally extensive or complex files, additional time and an additional fee may be necessary. For any additional work giving rise to an additional fee, the patient’s agreement is requested in advance, except in unforeseen medical circumstances.
Costs for additional laboratory investigations, imaging, technical examinations or services provided by external care providers are not included. Dr Werner Faché operates outside the national fee agreement (niet-geconventioneerd); no reimbursement through the health insurance fund is provided for this expertise.
5. Medical data
My medical data is treated confidentially and used solely within the framework of this expertise. Electronic health data is consulted only where the applicable legal conditions are met. Documents that are not available electronically may be provided through a suitable secure channel.
6. Declaration of consent
I have had sufficient opportunity to ask questions about the expertise, the procedure and the cost, and my questions have been answered to my satisfaction.
I give my consent for the file analysis and consultation described above and confirm that I have taken note of their independent and advisory character, as well as of the fact that this expertise does not entail any automatic taking over of the treatment or of further medical follow-up.
☐ I consent to consultation taking place, where relevant, with the following care provider(s):
………………………………………………………………………………………………………………
☐ I do not wish any consultation with third parties to take place without my prior, separate consent.
Patient’s name: …………………………………………………………………………………………..
Date: ……………………………………………………………………………………………………..
Patient’s signature (preceded by “read and approved”):
………………………………………………………………………………………………………………