File Number:

AUTHORIZATION FOR REPRESENTATION/PRIVACY ACT WAIVER

 

I,                                                       

                     (Name of Claimant)

 

                                                         

                    (Address of Claimant)

 

                                                         

                (City, State, Zip of Claimant)

 

do hereby authorize:

 

                                                         

      (Name of Representative/Person receiving records)

 

                                                         

     (Address of Representative/Person receiving records)

 

                                                         

 (City, State, Zip of Representative, Person receiving records)

 

                                                         

   (Phone Number of Representative/Person receiving records)

 

to (check all that apply):

 

     serve as my representative in all matters pertaining to the adjudication of my claim under the Energy Employees Occupational Illness Compensation Program Act of 2000.

 

     receive copies of all factual and medical evidence contained in my claim filed under the Energy Employees Occupational Illness Compensation Program Act of 2000 from the Office of Workers’ Compensation Programs, U.S. Department of Labor.

 

I declare that the foregoing is true and correct.  This authorization is effective on the date it is signed, and is effective until specifically revoked by me in writing.

 

                                                         

Signature                   

                            

Date