|
| Employee: Case ID: |
| ||
|
| ||||
| AUTHORIZATION FOR REPRESENTATION/PRIVACY ACT WAIVER
To provide that a duly authorized representative serves only the interest of the claimant, DEEOIC will not recognize the designation of an authorized representative whom DEEOIC finds is directly benefitting financially as a result of his or her affiliation with a claim, aside from the fee authorized by law. | ||||
| 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 administrative adjudication of my claim under the Energy Employees Occupational Illness Compensation Program Act of 2000 by the Division of Energy Employees Occupational Illness Compensation, Office of Workers’ Compensation Programs, U.S. Department of Labor.
| ||||
| _______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 Division of Energy Employees Occupational Illness Compensation, 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 of Claimant) (Date) | ||||