SOS Supportive Options & Solutions

Consent Form


This form serves as Authorization to complete my certificate for a Disability Tax Credit (DTC), to work with SOS Supportive Options & Solutions (SOS), and to release to SOS, on its request, a full copy of my medical records.

Attention:  
Date:  
Re: (Client Name):  

I have retained Supportive Options & Solutions (SOS) to represent me in regards to completing and filing a Disability Tax Credit Certificate T2201 (DTC).

Accordingly, I hereby authorize you:

  1. To complete the DTC and, if applicable any correspondence related to my DTC and to forward it to SOS whom I have granted authority to act as my exclusive representative in this matter;
  2. To work with SOS in completing the DTC and any correspondence related to my DTC: and
  3. To release to SOS all or a portion of my medical information, as it may request, including a full copy of my medical records (e.g. clinical chart, correspondence, and any documents that contain a summary of my medical condition).

 

Street Address:  
City:  
Province:  
Postal Code:  
Phone:  

Leave this empty:

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Signed by Nellie Krombach
Signed On: October 12, 2021


Signature Certificate
Document name: Consent Form
lock iconUnique Document ID: f7c177a0c4a4c3fffa31f10012e36a411b87c767
Timestamp Audit
September 1, 2021 4:36 pm PSTConsent Form Uploaded by Nellie Krombach - sosdtc123@gmail.com IP 68.150.248.156