Specialist Registration details

About you

Name*

Date of Birth*

Qualifications*

Contact e-mail address*

Contact telephone number*

GMC registration number*

Medical Defence Union details*

About your current post

Present post title*

Professional address*

Current employer*

Total number of years in a substantive Consultant post* (minimum 5 years)

5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 - 20 years 20 years plus

About your medicolegal work

List location(s) for your medicolegal assessments

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Do you perform home visits?

Yes  No

if yes please detail charges

Preferred instructions

Mental Health Act appeals

Yes  No

Adults with Incapacity Act assessments

Yes  No

Personal injury claims

Yes  No

Employment tribunal claims

Yes  No

Pension appeals

Yes  No

Please provide

3) cancellation charges and conditions (notice period in working days)

3)

Average number of medico-legal reports provided per year in the last three years: -

0 – 10

10 – 30

30 – 50   

more than 50

Average number of Court appearances per year in the last three years: -

0 – 5

5 – 10

more than 10

Declaration – all details provided are correct and I will update Insight Psychiatric Services with any changes, including to my GMC registration or Defence Union status.

Terms and conditions

(view the Terms & conditions on a seperate page)

Terms and Conditions – Consultant Psychiatrists Services By agreeing to the examination the medical expert will undertake the request as specified by Insight Psychiatric Services in accordance with the instructions provided. Consultant Psychiatrist’s Obligations a. The expert shall hold registration with the GMC in respect of their practice of medicine in the UK and will observe all requirements imposed by the GMC. b. The expert shall ensure that suitable and adequate professional indemnity insurance cover is in place for the purposes of this examination. c. The expert will undertake the requested examination in accordance with the instructions provided and ensure that any particular concerns or questions raised are addressed during the examination. The results of these concerns/questions will be included in the final report. d. The expert will undertake the examination with due care, skill and diligence and as part of the final report provide a resume of their experience and qualifications to demonstrate their relevant expertise. The final report shall be accurate and true to the best of their knowledge and belief. e. The expert shall provide the final examination report to Insight Psychiatric Services within 10 working days of the examination. f. The expert understands and agrees that the final report produced for Insight Psychiatric Services will be passed to their client for interpretation and use in the claim decision. g. The fee for the examination and provision of the final report will be in accordance with the communications with the examiner or his representative in advance of the instruction being allocated by Insight Psychiatric Services. h. The expert will request specific approval from Insight Psychiatric Services should there be additional costs incurred after accepting instructions. i. The expert will advise Insight Psychiatric Services within 24 hours in the event of non-attendance and advise the cost of such an occurrence subject to a maximum fee of £100. j. The expert shall indemnify and hold Insight Psychiatric Services harmless against all loss or damage caused to or suffered by Insight Psychiatric Services as a result of negligence by the expert. Fees and Expenses a. Insight Psychiatric Services will pay to the examiner the invoiced fee in accordance with the agreed instructions (or if a cancellation, the fee stated above). b. Fees will be payable by Insight Psychiatric Services to the expert 90 days from the end of the month in which the report is received by Insight Psychiatric Services. Information a. The expert shall in the course of this examination and thereafter agree to keep confidential all information concerning this examination and shall not use, discuss or attempt to use or discuss any confidential information. b. The expert shall use all reasonable endeavours to ensure that his/her secretary (or support staff as applicable) are made aware of the obligations in relation to confidentiality and ensure this is observed. c. The examiner shall comply with all relevant requirements of the Data Protection Act 1998 in carrying out this request for the provision of this service including a registration with the Data Protection Commissioner appropriate to the performance of this examination and final report. d. The expert shall be liable for and shall indemnify Insight Psychiatric Services against any expense, liability, loss, claim or proceedings arising from this examination. Assignment The expert shall not assign, transfer or sub-contract this examination to another expert.

I agree [until you agree to the terms you are unable to submit the form]