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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:

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;
To work with SOS in completing the DTC and any correspondence related to my DTC: and
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:

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Your legal name

Your email address

Please Confirm full name and signature.

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Signed by Nellie Krombach
Signed On: October 12, 2021

Timestamp

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September 1, 2021 4:36 pm PDT

Consent Form Uploaded by Nellie Krombach - [email protected] IP 68.150.248.156