Client Authorization
Statement of Authorization
Statement of Authorization
When we take on a new client, they need to sign a Statement of Authorization so we can legally speak on their behalf, and consult with doctors, pharmacists, or anyone whenever it applies.
Below is a sample of what one would look like, naturally each is different for who we represent.
Sample Statement of Authorization
I, _______________________, authorize the Connecticut Epilepsy Advocate Foundation and its President and Founder, Robert A. Fiore, to speak on my behalf and consult with my doctors, neurologists, pharmacists, insurance providers, and any other medical or administrative parties as required to assist with my Epilepsy-related care, medication access, and related matters.
Signed: _______________________________
Date: _______________________________
For a current form please call us at (203) 874-8731.
— The Connecticut Epilepsy Advocate Foundation is a recognized 501(c)(3) Nonprofit Organization. —
(203) 874-8731