Consent to Release Form

CONSENT TO RELEASE OF INFORMATION

RECITALS

WHEREAS, Client Name: (the "Client") is a natural person or entity possessing certain records, information and data related to the Client; and

WHEREAS, the Client desires to authorize the disclosure of specified records and information to the Recipient identified below for the limited purposes set forth in this Consent; and

WHEREAS, the Client acknowledges that this written Consent is provided voluntarily, after being informed of the scope, purpose and duration of the release, and with the right to revoke as provided below.

AUTHORIZATION TO DISCLOSE

I hereby authorize the disclosure of my records and information as described in this Consent from: Disclosing Party Name: , located at Address: .

RECIPIENT

SCOPE OF RELEASE

The Client authorizes release of the following categories of information (check all that apply):

Medical records, including treatment summaries, diagnoses, medication lists and laboratory results

Financial records, billing statements and payment history

Educational records, transcripts and evaluations

Employment records, personnel files and performance evaluations

Legal and case-related records

Tax records and filings

PURPOSE OF DISCLOSURE

AUTHORIZATION PERIOD

This authorization is effective as of Start Date: and will expire on End Date: unless earlier revoked in writing by the Client as provided below.

REVOCATION

The Client may revoke this Consent at any time by delivering a written revocation to the Disclosing Party at the address listed above. Revocation will not affect disclosures already made in reliance on this Consent prior to receipt of the revocation. Revocation must be signed and dated by the Client and specify the effective date of revocation.

CONFIDENTIALITY AND REDISCLOSURE

The Recipient is prohibited from redisclosing any information received pursuant to this Consent except as authorized by this Consent or as otherwise permitted or required by law. The Recipient must protect the confidentiality of the information with safeguards at least as protective as those used for the Client's own confidential information and must notify the Disclosing Party promptly of any unauthorized use or disclosure.

FEES AND COSTS

The Client understands that reasonable fees may be charged for duplication or retrieval of records. Any fees assessed by the Disclosing Party for fulfilling this request will be communicated in advance and must be paid by the Client unless otherwise agreed in writing.

REPRESENTATIONS, WARRANTIES AND LIABILITY

The Client represents that he/she/it is the individual or the authorized representative of the individual whose records are to be disclosed and has the legal authority to execute this Consent. The Client agrees to indemnify and hold harmless the Disclosing Party and Recipient from any claims arising from reliance on this authorization, except to the extent such claims are caused by the gross negligence or willful misconduct of the Disclosing Party or Recipient.

GOVERNING LAW

This Consent shall be governed by and construed in accordance with the laws of the State of: without regard to principles of conflicts of law, except where federal law applies and preempts state law.

ENTIRE AGREEMENT

This Consent constitutes the entire agreement between the parties concerning its subject matter and supersedes any prior oral or written statements, understandings, or agreements. Any modification to this Consent must be made in writing and signed by the Client and the Disclosing Party.

ACKNOWLEDGMENT AND CERTIFICATION

By signing below, the Client certifies that the information provided in this Consent is true and correct to the best of the Client's knowledge, that the Client has had the opportunity to ask questions regarding the content of this Consent and its consequences, and that the Client understands that the signature is voluntary.

CLIENT CONTACT INFORMATION

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