Doctor’s Form / Power of Attorney

Instructions for Authorized Representatives

 Important: only complete this form if you are an authorized representative. If the applicant can sign the form himself/herself, the doctor’s form is not required.

If claimant is unable to sign Claims Conference documentation, such as an application form or a life certificate, an authorized representative may sign on his/her behalf. The authorized representatives must submit ALL of the following documents to the Claims Conference:

  • Photocopy of a Power of Attorney or a document granting legal guardianship;
  • Photocopy of the authorized representative’s government issued ID;
  • Doctor’s Form completed by the claimant’s physician.

Please note: the doctor must have seen the claimant within the past two months in order for this form to be accepted by the Claims Conference.

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Doctor’s Form | Arztformular | טופס רופא  | Формуляр врача | Formulaire “Médecin”