Client Info Release

CLIENT INFO RELEASE

Parties

Recitals

WHEREAS, Client Name: (the "Client") has engaged certain services and maintains records and information that may be relevant to third parties; and

WHEREAS, Recipient Name: (the "Recipient") requests access to certain Client information for the limited purpose set forth below; and

WHEREAS, the parties intend to set forth the terms under which Client authorizes the disclosure of specified information to Recipient and to memorialize related payment, confidentiality, and termination provisions.

Authorization and Release

Client hereby authorizes and directs any entity in possession of Client's records to disclose and release to Recipient the categories of information expressly identified in this document. This authorization is limited to the information described in the Scope of Information section and for the purpose expressly stated below.

Scope of Work

Scope of Information

Client authorizes release of the following categories (select all that apply) and any ancillary documentation reasonably necessary to interpret such records:

Personal identifying information (name, date of birth, contact information)

Financial records (billing histories, invoices, payment records)

Service records (agreements, performance reports, case notes)

Other:

Purpose of Disclosure

Payment Terms

Client agrees to reimburse Recipient or pay the Provider for costs associated with obtaining, copying, and transmitting records as follows.

Term and Termination

This Release is effective as of Start Date: and shall expire on End Date: unless earlier terminated in accordance with this section.

Either party may terminate this Release for any material breach by the other party upon written notice delivered at least Notice Period: in advance. Termination shall not affect disclosures already made in reliance on this Release prior to the effective date of termination.

Revocation

Client may revoke this Release in writing at any time, except to the extent action has already been taken in reliance on this Release. Revocation is effective upon receipt by Recipient; however, disclosures made prior to receipt of revocation remain valid.

Confidentiality

Recipient shall treat all disclosed information as confidential and shall not use or further disclose such information except (a) as necessary to carry out the Purpose of Disclosure identified above, (b) as required by law, or (c) with the prior written consent of Client. Recipient shall implement and maintain administrative, physical, and technical safeguards to protect the confidentiality and security of disclosed information commensurate with industry standards.

Representations; Indemnification

Client represents that Client has the authority to authorize the disclosure of the designated information. Recipient agrees to indemnify, defend and hold Client harmless from any third-party claims, liabilities, losses, or expenses arising from Recipient's use or unauthorized disclosure of information beyond the authorized scope.

Governing Law

This Release shall be governed by and construed in accordance with the laws of the State of without regard to principles of conflicts of law.

Entire Agreement

This Release constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals, and communications, whether written or oral. Any amendment or modification to this Release must be in writing and signed by both parties.

Notices

All notices required or permitted under this Release shall be in writing and delivered to the addresses set forth above or to such other address as a party designates in writing.

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