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Texas Department of Agriculture Structural Pest Control Service

Authorization to Release Confidential Information

NAME:

(Name of Client)

ADDRESS:

(Street Number, Post Office Box, Route Number)

(City)

(State)

(Zip Code)

I authorize the following health care provider, attorney, counselor, school, etc.:

(Individual, Medical Doctor, Hospital, Clinic, Attorney, Counselor, School, Etc.)

(Street Number, Post Office Box, Route Number)

(City)

(State)

(Zip Code)

to release the following specific confidential information:

Yes [ ] No [ ] Developmental Information. Indicate specific information.

Yes [ ] No [ ] Medical Information. Indicate specific information.

Yes [ ] No [ ] HIV-Related Information. Indicate specific information.

Yes [ ] No [ ] Psychological Reports. Indicate specific information.

Yes [ ] No [ ] Social History. Indicate specific information.

Yes [ ] No [ ] Other. Indicate specific information.

to the Texas Department of Agriculture Structural Pest Control Service, P.O. Box 12847, Austin, Texas 78711-2847

Phone 866-918-4481; FAX 888-232-2567; E-mail: spcs@tda.state.tx.us; Web:

The information released may be used for the following purposes: Enforcement of the Texas Structural Pest Control Act & the

Federal Insecticide, Fungicide, and Rodenticide Act .

*****THIS FORM MUST BE SIGNED AND NOTARIZED*****

THIS AUTHORIZATION IS EFFECTIVE UNTIL I REVOKE IT IN WRITING.

This form (___) was read by me (___) was read to me and I understand its meaning. All the blanks were filled in before the form was

signed by me.

Date

(Signature)

(Print/Type Name of Person Authorized to Consent to Release of Information)

(Signature of Authorized Person)

(Relationship to Client

(Address)

(Telephone)

The State of Texas

County of__________________________)

Before me, the undersigned authority, a notary public in and for __________________________ County, on this day personally

appeared_______________________________ known to me to be the person whose name is subscribed to the foregoing

authorization to release confidential information to the Structural Pest Control Service of the State of Texas, and who by me being

duly sworn, on oath stated that the information given in the said application is true, correct, and complete.

Given under my hand and seal of office this ________ day of ____________________________ A.D. _________________

Notary Public in and For__________________________________ County,

Signature ______________________________________________________

Printed Name ___________________________________________________

My Commission Expires _________________________________________

Form Date 09/01/2007

Authorization To Release Confidential Information Form - Texas Department Of Agriculture Structural Pest Control Service Page 2

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