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FOIA(Freedom of Information Act) Office
Directions: Sample Consent Forms: ATSDR Adult
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FOIA(Freedom of Information Act) Office Directions: Sample Consent Forms: ATSDR Adult FOIA Home | Significant FOIAs | Contact Us |
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| TO: | Agency for Toxic Substances | Name: _______________________ | |||
| & Disease Registry | SS#: ________________________ | ||||
| FOIA Office | DOB: ________________________ | ||||
| 1600 Clifton Road, NE | Illness or Injury: __________ | ||||
| Atlanta, Georgia 30333 | _____________________________ |
I hereby authorize the Agency for Toxic Substances
and Disease Registry to release to ____________________
_______________________________________________________
any and all medical, confidential, employment, or other
information regarding me which it has in its possession.
_______________________________________
Signature
_______________________________________
Date
Notary insert
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This page last reviewed Friday, June 4, 1999
URL:
Freedom of Information Act Office
Centers for Disease Control and Prevention
and Agency for Toxic Substances and Disease Registry
Atlanta, GA