I, _____________________________,TDCJ-ID 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, disciplinary cases, legal, and any other information, records. documentation, communications pertaining to my incarceration which are currently, or in the future will be in the possession of the Texas Department of Criminal Justice-Institutional Division, Court System, Legal Counsel, Law Enforcement, University of Texas Medical Branch Hospital and/or Unit Infirmary, Texas Tech Health Sciences Center Hospital or University and/or Unit Infirmary including any outside medical care in hospitals, clinics, labs, doctor offices, any other unmentioned facilities that pertain to my health, legal issues/problems, life while in prison.

Further, I represent to all concerned, that I hereby elect and appoint People Against Prison Abuse aka PAPA in association with other associates that this organization feel can assist in these matters, to act as my lawful representative to do every and all things that I might so personally present in reference to my need for help to continue to allow myself to have a functionally healthy human type of life.

Moreover, I hereby authorize , People Against Prison Abuse aka PAPA in association with all other associates to do the following: ____Yes ___ NO

1. To Publish Electronically any and/or all portions of my medical records and other furnished information deem necessary and appropriate in seeking to obtain adequate medical care for myself and others in similarly situations.____Yes ____NO

2. To Publish Electronically any and/or all portions of my medical records and other furnished information deem necessary and appropriate in seeking to reveal the truths that are happening in the prison system via Assigned Code in place of my name, ID#, Unit name. ____ Yes ___NO

3. To refer or transfer any and/or all of my information to any other associations that will assist me with the issues and problems that I have written about. ____Yes ____NO

4.Contact of family members and/or significant others.____Yes ____NO

5.I represent to those dealing with my representatives that this appointment and waiver may be revoked only by,
____________________________________________________________________________,

TDCJ-ID NO. ______________, filing a formal written revocation which will be maintained on file in the Texas office of People Against Prison Abuse aka PAPA in association with all other associates, located at the address listed below:

People Against Prison Abuse aka PAPA
P.O. Box 12446
Odessa, TX 79768-2446

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 to the best of my ability. Affirmation pursuant to 28 U.S.C§1746.

On this ____day of__________, 20____

Signature_________________________________

Print Name ________________________________

Waiver of confidentiality has been:
1. Transferred to:

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3. Additional Help requested from:

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©People Against Prison Abuse aka PAPA June 1994 ©