Third-party Consent Form

Form giving third party consent

The NHS Counter Fraud Authority (NHSCFA) is required by law to keep information confidential. Unless a legally permitted exemption applies the NHSCFA will only share your information if we have your consent to do so.

Please complete this form to allow a nominated person or organisation (third-party) to communicate with NHSCFA on your behalf.

You must carefully consider what information they may learn about you as a result.

If you are unsure about giving third-party consent, you are strongly advised to seek appropriate legal advice before proceeding.

The granting of consent will only be used for the specific purpose of responding to this enquiry.

Please ensure both sections are properly and fully completed. If the form is incomplete, we will not be able to comply with your request.

Section 1

  • I want to nominate the person or organisation named below to correspond with NHSCFA on my behalf. This will include receiving personal and sensitive information about me.
  • I understand that giving my consent will allow the nominated person or organisation to communicate with NHSCFA about me, while my enquiry is being dealt with.
  • I understand the risk of my information being shared by my nominated person or organisation and understand that NHSCFA has no control over this. In signing this form, I accept any risks associated with providing third-party consent.
  • I understand that the sharing of information with the person or organisation I have nominated will start when NHSCFA receives the signed consent form and understand that this will remain in place until the conclusion of the matter, or until I restrict/withdraw consent.
  • I understand that I will not receive any correspondence from NHSCFA until the matter is concluded/final determination is made. I understand that the person or organisation I have nominated will be made aware that the matter has been closed.
  • I understand that this third-party consent will be reviewed annually should my enquiry still be ongoing, and I understand that if I do not respond to a requested review, NHSCFA will start communicating directly with me again.
  • I understand I can restrict or withdraw my consent at any time by contacting

NHSCFA and confirming in writing.

Your signature:

…………………………………………………………………………

Print name:

…………………………………………………………………………

Date:

…………………………………………………………………………

Nominated person’s or/organisation’s name:

…………………………………………

Relationship:

…………………………………………………………………………

Address (including postcode):

…………………………………………………………

…………………………………………………………………………

…………………………………………………………………………

Telephone number:

…………………………………………………………………

Nominated person’s email address only:

…………………………………………

Section 2

To be completed by the nominated third-party.

By agreeing to act as the third-party for the above-named person, I understand that I will be able to give and receive information about them. All future communication sent from NHSCFA will be supplied to me with the exception of the final decision, which will be sent to the above-named person directly.

If I wish to withdraw my position as a third-party to the above-named individual I will inform NHSCFA immediately in writing.

Nominated person’s signature:

……………………………………………………………

Print name:

……………………………………………………………………………

Date:

…………………………………………………………………………..

Please inform NHSFCA immediately if you do not want to be the nominated third-party.