Authority to Act on Behalf - Carers of East Lothian

Consent to share personal information:

Grantor's Details

Grantor's Name(Required)

First Last

Address(Required)

Postcode(Required)

National Insurance Number

Date of birth(Required)

Day

Month

Year

I acknowledge and agree to the representative detailed below sharing my financial and /or support needs information with Carers of East Lothian (CoEL). I understand that this is so advice/information and support can be provided to me in relation to welfare benefits and my individual support needs. I understand that if any benefit entitlement is identified and assistance agreed, that I will be required to complete a further mandate authorising CoEL to act on my behalf.

Representative's Details

PLEASE PRINT CLEARLY IN BLOCK CAPITALS

Name(Required)

First Last

Address(Required)

Postcode(Required)

Date of birth(Required)

Day

Month

Year

Relationship to Grantor(Required)

By signing this consent form I agreed and understand the above information. I also understand that CoEL will maintain a record of this and any personal information in the course of providing assistance to me and authorise them to do so.

Grantor Signature(Required)

Date(Required)

Day

Month

Year

Representative Signature(Required)

Date(Required)

Day

Month

Year

Privacy Notice

By law, all organisations that use personal information (personal data) must provide a clear description of how it is used and also provide any related information to ensure the processing is carried out lawfully and fairly. CoEL’s main Privacy Notice is available on our website – www.stg-carersofeastlothian-coelstaging.kinsta.cloud/privacy. We encourage you to read this, so you are fully informed of your personal data processing rights. Please contact 0131 665 0135 if you need alternative format such as print or braille. If you have any specific concerns regarding the processing of your personal data you can contact our Data Protection Manager, Carers of East Lothian, East Lothian Community Hospital, Alderston Road, Haddington, EH41 3PF, email chiefexecutive@coel.org.uk or telephone 0131 665 0135.

Disclaimer

Our organisation provides advice and advocacy based on information provided by the service user at the time of giving that advice. The service bases its advice on legislative information, case law and any other guidance currently available. Whilst every effort is made to ensure that advice given is accurate and up to date the organisation cannot accept any responsibility or liability for any inaccuracies or incomplete information.