FOIA Request Consent Form

FOIA Request Consent Form

This FOIA Request Consent Form is entered into on this Effective Date: , by and between Requestor Name: (Requestor) and Subject Name: (Subject).

RECITALS

WHEREAS, Subject is an individual who possesses or whose personal information may be contained within records maintained by the agency or public body identified as Agency Name: ; and

WHEREAS, Requestor seeks disclosure of certain records under applicable public records laws and has requested that Subject provide written consent to the release of records that would otherwise be subject to privacy protections; and

WHEREAS, Subject is willing to consent to the release of specified categories of records to Requestor under the terms and conditions set forth herein.

NOW THEREFORE, in consideration of the mutual covenants and promises contained herein, the parties agree as follows:

1. AUTHORIZATION AND SCOPE

1.1 Subject hereby authorizes and directs the agency identified above to disclose and provide to Requestor all Records described in Section 1.2 that pertain to Subject, to the fullest extent permitted by law. This authorization expressly includes any records maintained in electronic or paper form and covers records created prior to, on, or after the Effective Date unless otherwise limited below.

1.2 Categories of Records Authorized for Release (check all that apply):

Medical, health or clinical records

Personnel, employment or disciplinary records

Financial, billing or insurance records

Correspondence, complaints or investigative files

2. REPRESENTATION AND PURPOSE

2.1 Requestor represents that the Records requested are sought for the following purpose:

2.2 Requestor certifies that the Records will not be used to harass, defame or otherwise unlawfully harm Subject and that Requestor will comply with all applicable statutes, rules and agency procedures relating to public records requests.

3. LIMITATIONS; REDACTIONS

3.1 Subject acknowledges that certain information may be exempt from disclosure under applicable law and that the agency may withhold or redact portions of Records as required by statute, regulation, or legal privilege. Subject does not condition this consent upon the agency’s forgoing of a lawful redaction or exemption determination.

3.2 This Consent does not waive Subject’s rights in relation to records held by third parties nor does it require any agency to create new records. Subject expressly waives any claim arising solely from the agency’s release of records in compliance with this Consent and governing law, except to the extent release exceeds lawful authorization.

4. FEES AND COSTS

4.1 Requestor agrees to pay reasonable copying, search, and review fees assessed by the agency in connection with fulfillment of the request. Requestor may limit fees by specifying a maximum amount below. If fees are estimated to exceed the stated limit, the agency may suspend processing until Requestor agrees to pay the excess.

5. INDEMNIFICATION

5.1 Requestor shall indemnify, defend and hold harmless Subject and the agency from and against any and all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising out of Requestor’s receipt, use or further disclosure of Records provided pursuant to this Consent, except to the extent caused by the gross negligence or willful misconduct of the agency.

6. TERM AND REVOCATION

6.1 This Consent is effective as of the Effective Date and shall remain in effect for a period of years unless earlier revoked in writing.

6.2 Revocation shall be effective only upon receipt by the agency of written notice of revocation delivered in accordance with the Notices provision below and shall not affect disclosures made in reliance on this Consent prior to the agency’s receipt of such notice.

7. NOTICES

All notices, requests, consents and other communications required or permitted under this Consent shall be in writing and delivered to the addresses provided below. Notice shall be deemed given upon personal delivery, one business day after delivery by nationally recognized overnight courier, or three business days after deposit in the United States mail, postage prepaid, addressed as follows:

8. MISCELLANEOUS

8.1 Governing Law. This Consent shall be governed by and construed in accordance with the laws of the jurisdiction in which the agency is located, without regard to its conflict of laws principles.

8.2 Entire Agreement. This Consent constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, representations and warranties, whether written or oral.

8.3 Severability. If any provision of this Consent is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired thereby.

8.4 Amendment and Waiver. No amendment or modification of this Consent shall be effective unless in a written instrument signed by both parties. No waiver of any breach shall constitute a waiver of any other breach.

8.5 Counterparts; Electronic Signatures. This Consent may be executed in counterparts, each of which shall be an original and all of which shall constitute one instrument. Signatures transmitted by electronic means shall be deemed originals for all purposes.

ADDITIONAL AUTHORIZATIONS

Representative Authorization: If Requestor is acting as a representative of Subject, indicate authority and provide identification below. Requestor certifies the authority to act on behalf of Subject by checking the box and completing the representative fields.

Requestor is authorized representative of Subject

CERTIFICATION

By signing below, Subject certifies that they are the person identified herein or a legal guardian or authorized representative of the person identified, and that the information provided in this Consent is true and accurate to the best of their knowledge. Requestor certifies that statements made herein are true and that Requestor will comply with the terms of this Consent and applicable law.

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