Medical authorisation1Introduction2Personal data3List4SignatureYour employer/company doctor/medical adviser has referred you for an examination by a Second Opinion company doctor. The purpose of this examination is to gain as complete a picture as possible of your medical complaints, the treatment options and your ability to work. To this end, it is important that our insurance doctor has access to the necessary medical information. We require your consent to exchange your medical information during this process, which you can provide using this authorisation form.Naam* First name Last name Adres* Street + housenumber City Postal code Phone number*Phone number #2E-mail* Date of birth* DD dash MM dash YYYY Doctors, including company doctors and general practitioners. Please note: By using the plus sign on the right-hand side, it is possible to add multiple lines.ListNameSpecialisation/functionName of hospital/practice The undersigned hereby grants permission for the exchange of medical data between his/her referring treating physician(s) and Mr W.G.J. Berkhout, medical advisor at the Second Opinion Bedrijfsarts medical expertise centre. The information provided will be used to advise on the undersigned’s capacity for work. By means of this authorisation, the undersigned also grants Second Opinion Bedrijfsarts permission to send the final report (non-medical) to the reintegration manager or employer.The undersigned will receive a copy of the completed form by email afterwards.Consent* I agree to the privacy policy.Completed truthfully* The undersigned declares that this form has been completed truthfully and agrees that the information provided will be verified.Date of signature* DD dash MM dash YYYY Signature
