Disability Allowance Form Page 29
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36ED13068E
Part 11
Permission to release medical information
Please sign the authorisation below, which will allow your doctor to give this Department the
necessary medical information for your application for Disability Allowance. Your doctor should
then complete Part 12 of this form.
The medical information provided will be reviewed by one of our medical assessors and will be
treated in strictest confidence. Although a confidential document, medical and non-medical people
will need to deal with this report.
Permission
I permit my doctor to provide you, the Department of Social Protection, with medical
information that may be required for my application for Disability Allowance.
2 0
Date:
D D
M M
Y Y Y Y
Signature (not block letters)
If you are unable to sign, have your mark witnessed and have the witness sign below for you:
2 0
Date:
D D
M M
Y Y Y Y
Witness Signature (not block letters)
7432382313
7432382313
7432382313
7432382313
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