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In accordance with the Privacy Act of 1974 (5 USC 552), I hereby authorize Representative Tom Price and his designated staff to seek disclosure of all records relevant to my case from the federal agency involved. (Under the Privacy Act of 1974, we must have formal authorization from you before seeking disclosure of your records. The authorization must be signed by the person whose case is in question.) Signature:_______________________________________________ Date:________ Description of Problem:__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Attach additional pages if necessary. Attach photocopies (no originals please) of all relevant documents.
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