Authorization for Texas Worker’s Compensation Commission Records

TO WHOM IT MAY CONCERN:

Upon presentation of the original or copy of this authorization, I hereby authorize all persons, companies or entities to provide [ATTORNEY NAME/FIRM NAME AND ADDRESS] with a complete copy of all records in your possession regarding me.

This request is intended to be as broad as possible and include, but not be limited to, a complete copy of all Industrial Accident Board or Texas Worker’s Compensation Commission records pertaining to me. This includes, but is not limited to, all claims files and records, all hearings and decisions.

I fully discharge and release from any liability any person, company or entity who produces records, files or other documents pursuant to this authorization.

My full name is ____________________________________________________.

My date of birth is __________________________________________________.

My Social Security number is _________________________________________.

Former name(s) under which I have been known is/are:

_____________________________________________________________________________.

________________________________________________

SIGNATURE

THE STATE OF TEXAS §

§

COUNTY OF __________ §

Before me, the undersigned authority, on this day personally appeared __________________, known to me to be the person whose name is subscribed to the foregoing instrument, and who, after being by me duly sworn, upon his oath states that same was executed for the purposes therein expressed.

SUBSCRIBED AND SWORN TO BEFORE ME on this ____________ day of _____________________, 20____.

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Signature of Notary Public

________________________________________________

Printed Name of Notary Public

My Commission Expires:

___________________________

WAIVER OF CONFIDENTIALITY

I have, and by this instrument, do hereby authorize the Texas Worker’s Compensation Commission or the Industrial Accident Board of Texas and request of you the release of any and all information concerning any of my worker’s compensation claims or files which may be...