Client Consent Change Form

CLIENT CONSENT CHANGE FORM

Parties and Identifying Information

WHEREAS (Recitals)

WHEREAS, Client Name: previously provided written consent to Provider Name: on Original Consent Date: for the performance of services and the use or disclosure of certain client information.

WHEREAS, the parties now desire to amend and restate certain elements of that consent in accordance with the terms set forth in this Client Consent Change Form to reflect changed scope, duration, or other conditions of consent.

WHEREAS, the parties intend that this document operate as a binding amendment to the original consent to the extent permitted by law and as described in the sections below.

Scope of Change

Describe the specific change(s) to the original consent (check applicable and provide detailed description):

Modify scope of services or disclosures
Extend duration of previously granted consent
Revoke previously granted consent in whole or in part
Other (specify below)

Scope of Work (If Applicable)

Set forth any specific tasks, services, or disclosures that are newly authorized, modified, or restricted as a result of this change.

Payment Terms (If Applicable)

If the change to consent alters the cost or payment obligations, describe amounts and schedule below. If no payment is required, enter "N/A."

Term and Termination

This amendment is effective as of Effective Date: and shall continue until End Date: unless earlier terminated pursuant to this section.

Either party may terminate this amendment for convenience upon providing Notice Period (days): days prior written notice to the other party. Termination shall not relieve the parties of obligations accrued prior to termination, including any payment obligations or confidentiality duties.

Confidentiality

All non-public information exchanged under or in connection with this change in consent shall be treated as Confidential Information. Each party agrees (i) to use Confidential Information only for purposes permitted by this amendment, (ii) to limit disclosure of Confidential Information to employees, contractors or agents who have a need to know and who are bound by confidentiality obligations at least as restrictive as those contained herein, and (iii) to take reasonable measures to protect Confidential Information from unauthorized use or disclosure. Exceptions include information that is independently developed, becomes publicly available through no breach, or is required to be disclosed by law or valid legal process, in which case the disclosing party will provide prompt written notice to the other party where lawful and practicable.

Representations and Warranties; Client Acknowledgment

The parties represent and warrant that they have the authority to enter into this amendment and that the person signing below on behalf of each party is authorized to bind that party. Client acknowledges receipt of the detailed description above and understands the consequences of modifying, extending, or revoking consent. Client further acknowledges that changes may affect the provision of services and any associated fees.

Client acknowledges and accepts the changes described in this form.

Governing Law

This amendment shall be governed by and construed in accordance with the laws of the jurisdiction specified below, without regard to conflict of law principles.

Entire Agreement

This Client Consent Change Form, together with the original consent documents expressly referenced herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and communications, whether written or oral, relating to the subject matter. No amendment to this form will be effective unless in writing and signed by authorized representatives of both parties.

Miscellaneous Provisions

If any provision of this amendment is held to be invalid or unenforceable, the remaining provisions will remain in full force and effect. The headings in this amendment are for convenience only and will not affect interpretation. Any notices required hereunder shall be in writing and delivered to the contact information set forth above or such other address as a party may specify in writing.

Optional Additional Instructions

Sign Now