I, ______________________, (File Number ____________), residing at ____________________________, am aware that persons other than claimants involved in the above case or their authorized representative may be present at a hearing convened under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA) on ______________, at _____ AM/PM in _________________, in the State of _____________________.  

I have requested the presence of these persons, or accept their presence at this proceeding, and I hereby waive any right to confidentiality of records, documents or other materials contained in files maintained by the Office of Workers’ Compensation Programs and disclosed during the hearing.  I further waive any right to privacy under the Privacy Act of 1974 in the disclosure of records, documents or other materials related to my claim that may be released during the course of the hearing.


Acknowledged and signed this ______day of ________, 2009.