POWER OF ATTORNEY – RELEASE OF REPORT CONSENT FORM

POWER OF ATTORNEY – RELEASE OF REPORT CONSENT FORM
Referred individual’s details:
First Name:*
Surname:*
Date of Birth:*
Preferred telephone number:*
Preferred Email:*
Enter Email Confirm Email
Power of attorney’s details:
First Name:*
Surname:*
Date of Birth:*
As power of attorney acting on behalf of the named individual above, I confirm that I understand and agree:
- I have gained the relevant legal authority to act as Power of Attorney on behalf of the referred individual.
- The reason and purpose of the referral has been explained to me and I am willing for them to undergo the assessment.
- Following the assessment, a report can be sent to the referring party. The subsequent report will contain information and impartial advice resulting from the assessment.
- That the assessment may include a physical examination and/or tests but these will be explained to me if they are required.
- To assist with the referral, Innovate may wish to write to their doctor to request medical information about them (doctor being their GP, family doctor or in the case of hospital or outpatient treatment, their relevant treatment specialist).
- Their personal and medical information will be maintained and processed confidentially by Innovate Healthcare staff, in accordance with the DPA (2018).
- I have the right to revoke consent at any time, however, any data processing that occurs before consent is revoked will still be valid. I can revoke consent by writing to Innovate at the address given on this form (via post or email).
Your Consent:
I _ _ _ _ _ _ _ _ _ _ confirm that I have read and understood this Consent Form and hereby give Innovate my consent, as the power of attorney, to obtain, use and disclose information about the referred individual as described in this form. I agree that a copy of this Consent Form will be as valid as the original. Innovate will consider my signed consent valid for two years from the date of signature unless instructed otherwise by me
Signature:*
Print Name: _ _ _ _ _ _ _ _ _ _
Today's Date : 27/04/2024
How we use your information:
In order for Innovate Healthcare to assist with the referred individual’s rehabilitation needs we may need to obtain information during the assessment regarding their personal situation, medical history, current injury and employment/vocational status.
Once an assessment has been completed, we will write a report detailing the relevant things we have discussed with you/them/their representatives and send it to their insurance company with the aim of advising them on how they can support you. The report may therefore include impartial advice resulting from the assessment to inform recommendations to support a return to function/work. Calls to/from Innovate Healthcare are recorded for monitoring and training purposes.
Your right of access:
European Regulation provides you (“the Data Subject”) with the right to obtain access to personal data that we hold about you. Personal data is defined as “data from which a living individual can be identified or identifiable (by anyone), whether directly or indirectly, by all means reasonably likely to be used”. You can make a subject access request by writing to Innovate, including your full name, address and contact telephone and include details of the specific information you require and any relevant dates.