Casework Privacy Release

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Senator Dianne Feinstein

Privacy Release Form

Complete, sign, and return to:

casework@feinstein.senate.gov

or

SENATOR DIANNE FEINSTEIN

ONE POST STREET, SUITE 2450

SAN FRANCISCO, CA 94104

Attn:

For Office Use Only

People ID#

For Office Use Only

Date: *

MM/DD/YYYY

First Name *

Last Name *

Address *

City *

State *

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Zipcode *

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Email Address

Federal Agency Involved *

Agency File #

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Social Security #

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Date of Birth

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Medicare Beneficiary Identifier (if applicable)

For Medicare and Medicaid related requests only

Have you contacted our office before? *

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Have you contacted another congressional office regarding this matter? *

Yes No

If you answered "yes" above, which office and when did you contact them?

If another congressional office is currently working on your case, it is best to continue working with that office. Duplicate inquiries from multiple congressional offices will not result in a more favorable response from the agency, and may slow down the agency’s response times.

Is this matter currently pending before a local, state, or federal court? *

Yes No

Please briefly explain your problem and outline the steps that have been taken by you and the agency with regards to your situation. In addition, please make your request for assistance as specific as possible. Should you require more room, feel free to attach a letter addressed directly to the senator. *