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Date
TO WHOM IT MAY CONCERN:
Persuant to the provisions of 5, U.S.C. 552a (Privacy Act of 1974) PL 93-579, I hereby authorize the release of information from, or copies of, my medical or any other records or files pertaining to me, to Congressman Mike Doyle.
Signature: __________________________________
Send this request to:
Congressman Mike Doyle
225 Ross Street
5th Floor
Pittsburgh, PA 15219
Phone: 412-261-5091
Fax: 412-261-1983
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