Consent Form for Release of Information to a Third

Document Sample
Consent Form for Release of Information to a Third Powered By Docstoc
					Consent Form for Release of Information to a Third Party
I (insert name of patient/recipient of care)

………………………………………………………………………………………………….

of (insert address of patient/recipient of care)

………………………………………………………………………………………………….

………………………………………………………………………………………………….

do hereby give my consent for (insert name of person acting on your behalf)

………………………………………………………………………………………………….

of (insert address of person acting on your behalf)

………………………………………………………………………………………………….

………………………………………………………………………………………………….

to pursue a complaint on my behalf.

I understand that the release of this information is to be used to:
   explore possible actions or solutions that might resolve the concerns that I have
    raised;
   inform investigation and response in regard to the progressing of a complaint under
    the NHS Complaints Procedure.

I understand that the information released under this authority may include both clinical
and non-clinical information relating directly to me.

I also understand that other officers of the Trust from outside the Complaints
Department may be contacted, and that my details might be shared with them, as far as
this helps to assist resolution of the concerns raised on my behalf. However, all officers
of the Trust are bound by a corporate requirement to maintain standards of
confidentiality as regards patient information and details.




Signed     ………………….………………………………………………………………….

Date       ……………………………………………………………………………………..


    Chair: Glyn Shaw                                    Chief Executive: Gary Graham