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This power of attorney can be used, if you want to give another person authorisation to complain on your behalf. Once you have given another person authorisation to complain we will no longer write to you, but to the person who
has received authorisation from you.
You can, at any time, withdraw this power of attorney by contacting us.
You must sign the power of attorney by hand and send it to us electronically, for example by scanning it or taking a picture of it.
Power of Attorney
Styrelsen for Patientsikkerhed
Visitation og Sagkyndige
Finsensvej 15
2000 Frederiksberg
Dir. tlf. +45 7228 6765
Telefontid: 9:30-15:00
Case no.:
My name:
My cpr.nr. (if possible):
stps@stps.dk
www.stps.dk
My telephone no.:
I hereby give power of attorney to:
Name:
Adress:
Telephone no.:
I hereby authorise the above-mentioned person to complain
to the Danish Patient Safety Authority on my behalf and to
handle my interests regarding the case.
Date
My handwritten signature