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REDACATED

 I request that any and all records be delivered to the attention of William Bock, General
Counsel, United States Anti-Doping Agency, 5555 Tech Center Drive, Suite 200, Colorado
Springs, Colorado 80919-9918, (719) 785-2000, email: wb@usada.org and that you provide the
foregoing information to USADA, including through discussing my care with USADA and
submitting to a deposition, as requested by USADA.

I understand that once delivered to USADA, the requested records will be maintained in
strict confidence by USADA in accordance with the World Anti-Doping Agency International
Standard for the Protection of Privacy and Personal Information and used only for anti-doping

purposes as specified in that Standard.

Please note that to the extent that any of the foregoing informatio @vered by any
confidentiality obligation such as the physician-patient, other patient
privilege or by any other health privacy laws I hereby waive such privileg and/or confidentiality
to the extent necessary to permit complete disclosure to, and use ADA. Disclosure of this
information and your cooperation with USADA is essential to my nal and professional
wellbeing, and I request that you and all Health Care Providers and completely cooperate

with investigation.


Name of Patient: 

  
    
   
 

  

Date of Birth:

Social Security 

 

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