![](media/image1.png){width="4.073611111111111in"
height="0.8513888888888889in"}

> CONSENT FOR RELEASE OF INFORMATION

Due to the restrictions of the Privacy Act of 1974, a signed consent
form must be returned to Senator Bob Corker to allow for the viewing of
any personal files and information.  The information includes, but is
not limited to, medical records relative to the inquiry.

**To begin processing your request, please complete the following
information (Please Print):**

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_ Zip: \_\_\_\_\_\_\_\_\_ County:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Phone Number(s) -- Home: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Work: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Cell:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Fax:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Social Security Number: \_\_\_\_\_\_ -- \_\_\_\_ -- \_\_\_\_\_\_\_\_
Date of Birth (mm/dd/yyyy):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Briefly explain your problem and/or desired information *(Include
additional pages if needed or copies of any documentation that you may
have which would help expedite your inquiry. Please do not send original
documents.)*

In keeping with the Privacy Act of 1974; I
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, authorize any
federal agency or department relative to my case, to provide information
regarding my case/claim to U.S. Senator Bob Corker and staff. 

Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Please Return Completed Form and Documents to the Field Office Serving
the County in Which You Reside**

***(see next page)*.**

**United States Senator Bob Corker**

**Field Office Locations**

**Chattanooga:**

 

> 10 West MLK Blvd., 6th Floor
>
> Chattanooga, TN 37402

Phone: 423-756-2757

Fax: 423-756-5313

 

*Serving:* Bledsoe, Bradley, Coffee, Franklin, Grundy, Hamilton,
Lincoln, Marion, McMinn, Meigs, Moore, Polk, Rhea, Sequatchie, Van
Buren, Warren and White.

 

**Jackson:**

 

> Ed Jones Federal Building
>
> 109 Highland Ave., Suite B8
>
> Jackson, TN 38301

Phone: 731-424-9655

Fax:  731-424-8322

 

*Serving:* Benton, Carroll, Chester, Crockett, Decatur, Gibson,
Hardeman, Hardin, Henderson, Henry, Haywood, Lawrence, Madison, McNairy,
Obion, Perry, Wayne and Weakley.

 

**Knoxville:**

 

> 800 Market Street, Suite 121
>
> Knoxville, TN 37902

Phone:  865-637-4180

Fax: 865-637-9886

 

*Serving:* Anderson, Blount, Campbell, Clay, Cumberland, Fentress, Knox,
Loudon, Monroe, Morgan, Overton, Pickett, Roane, Scott and Union.

 

**Memphis:**

 

> 100 Peabody Place, Suite 1335
>
> Memphis, TN 38103

Phone:  901-683-1910

Fax: 901-575-3528

 *Serving:* Dyer, Fayette, Lake, Lauderdale, Tipton and Shelby.

 

**Nashville:**

 

> 3322 West End Ave., Suite 610
>
> Nashville, TN 37203

Phone:  615-279-8125

Fax:  615-279-9488

 

*Serving:* Bedford, Cannon, Cheatham, Davidson, DeKalb, Dickson, Giles,
Hickman, Houston, Humphreys, Jackson, Lewis, Macon, Marshall, Maury,
Montgomery, Putnam, Robertson, Rutherford, Smith, Stewart, Sumner,
Trousdale, Williamson and Wilson.

 **Tri-Cities:**

 

> Tri-Cities Regional Airport
>
> 2525 Hwy 75, Suite 126
>
> Blountville, TN 37617

Phone:  423-323-1252

Fax:  423-323-0358

 

*Serving:* Carter, Claiborne, Cocke, Grainger, Greene, Hamblen, Hancock,
Hawkins, Jefferson, Johnson, Sevier, Sullivan, Unicoi and Washington.

Mail or fax the completed form addressed to "U.S. Senator Bob Corker." 
Be sure to include the appropriate office address for the county in
which you live.