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Texas Income Protection Plan for State Employees, ERS

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Authorization to Obtain and Disclose Information Form

The Authorization to Obtain and Disclose Information Form (83k) allows your treating and other health care provider(s) to inform us about your disability claim. You must sign and date the Authorization Form and give a copy to your treating health care provider(s). The original form must be completed and faxed or mailed to TIPP Customer Care (fax number and address are shown on the form).


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