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Consent to Disclosure form

Aug 12, 2022 | Resources | 0 comments

If we are assisting you with your case the NMC will require a consent form from you – ask them to email to you or copy and paste in a word document the text below and complete it that way

___________________________

Consent form for disclosure to representative

 

If you want someone to act on your behalf in relation to your fitness to practise case we require your explicit consent. This is so we can share your case papers and communicate with them about your case.

If you give us your consent to share information about your case, the information we’ll share with them will include:

  • your name, date of birth and contact information
  • unique identifiers (such as PIN, PRN, employee number)
  • details of the circumstances of the referral (including conduct and behaviour allegations or health matters)
  • employment history, and any other information where it is needed to progress our investigation
  • the case papers – including the evidence we have so far, and any future information in relation to your case.

The information we’ll share could include sensitive and confidential information about you.

At any time you can withdraw your consent for us to share information with your representative or tell us if you no longer wish the nominated person to act on your behalf. You can do this by informing your case officer.

Case reference:

Full name:

I confirm that the person named below will be acting on my behalf. I give my explicit consent for the NMC to communicate about my case and share information about my case with the person named below. I expressly agree to the disclosure of all information related to my fitness to practise case with the person named below and understand that the information could include sensitive and confidential information about me.

If I change my representation or the person below is no longer acting on my behalf, I will inform the NMC in writing immediately.

Signed:      …………………… Name:      ……………………… Date:      …….

Representative’s details

Name:           ………………………………………………………………………………………………………………

Address:      ………………………………………………………………………………………………………………

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

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

Phone:          …………………………………… Email:        …………………………………

 

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