"EXPRESS WAIVER"

"Express Waiver Of Confidentiality"

I,___________________________; TDCJ-CID No:________________ being competent to execute this waiver of confidentiality and over the lawful age of twenty-one (21), state that I do hereby expressly wave any and all rights of confidentiality to any and all medical records, or forms of communications relative to any and all medical records and/or information(s) concerning medical records which are currently, or in the future will be in the possession of the Texas Department of Criminal Justice-Corrections Institutional Division, University of Texas Medical Branch Hospital or Unit Infirmary or Texas Tech Health Sciences Center Hospital or University or Unit Infirmary.
Futher, I represent to all concerned that I hereby elect and appoint Dwight Rawlinson of The Texas Prison Labor Union to act as my lawful representative to do every and all things that I might so personally present.
Moreover, I hereby authorize Dwight Rawlinson to possess, copy or publish electronically any and/or all portions of my medical records as he my deem necessary and appropriate in seeking to obtain adequate medical care for myself and others similarly situated.
I represent to those dealing with my representatives that this appointment and waiver may be revoked only by my personally filing a formal written revocation which will be maintained on file in the National offices of the Texas Prison Labor Union: 2121 S. 4th. St., Waco, Tx 76706-3265

Verification:
I, __________________________ do hereby verify on my oath and under penalty of perjury that the statements and facts set forth in the foregoing Express Waiver of Confidentiality are true and correct.

Affirmation pursuant to 28 U.S.C§1746.
________on this ____day of__, 20__
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Signature
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