Information Disclosure Authorization Form

INFORMATION DISCLOSURE AUTHORIZATION FORM

Parties

Discloser Name:

Recipient Name:

Recitals

WHEREAS, Discloser possesses certain confidential, proprietary, or personally identifying information described in this Authorization that may be necessary for Recipient to perform business functions, fulfill a legal obligation, or evaluate an application or claim; and

WHEREAS, Discloser is willing to permit the disclosure of specified categories of information to Recipient for the purposes and under the conditions set forth below, subject to the terms and conditions of this Authorization; and

WHEREAS, Recipient requires written authorization from Discloser to collect, use, retain, or redisclose such information and agrees to comply with applicable confidentiality obligations and limitations on use;

Scope of Information

Special handling required for certain categories (check all that apply):

Medical or health information
Financial or credit information
Employment or payroll records
Academic or disciplinary records
Other (describe):

Permitted Use and Recipients

Purpose of disclosure:

Payment Terms

Fee for processing disclosure (if applicable): $

Late fee or interest on overdue amounts:

Term and Termination

Authorization Start Date:    Authorization End Date:

Either party may terminate this Authorization by delivering written notice to the other party. Notice period (days):

Upon termination, Recipient will promptly cease further disclosures and return or destroy disclosed records consistent with applicable law and any separate retention obligations. Notwithstanding termination, recipient obligations with respect to information already received shall survive to the extent required by law or contract.

Confidentiality

Recipient acknowledges that disclosed information may be confidential or legally protected. Recipient shall: (a) restrict access to authorized personnel on a need-to-know basis; (b) implement reasonable administrative, technical and physical safeguards to protect confidentiality and integrity; (c) use the disclosed information solely for the permitted purposes set forth herein; and (d) not redisclose such information except as expressly permitted by this Authorization or required by law.

If redisclosure is permitted, the Recipient must obtain written assurances from any third-party recipient to maintain confidentiality to a level at least equivalent to this Authorization.

Representations, Warranties and Liability

Discloser represents that it has the authority to authorize the disclosure of the information described herein. Recipient represents that it will comply with the terms of this Authorization. Neither party shall be liable for disclosures made in good faith and in compliance with this Authorization, except for willful misconduct or gross negligence. To the extent permitted by law, Recipient's liability for breach of confidentiality shall be limited to actual damages proven and shall not include punitive damages unless required by law.

Governing Law

This Authorization will be governed by and construed in accordance with the laws of the state of , without regard to its conflicts of law principles.

Entire Agreement

This Authorization constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior or contemporaneous oral or written agreements, understandings, representations and communications relating to disclosure of the specified information. Any amendment must be in writing and signed by both parties.

Consent and Certification

By signing below, the undersigned certifies that they are the individual whose information is to be disclosed, or an authorized representative with authority to execute this Authorization on behalf of the individual or entity. The undersigned authorizes the Discloser to release the categories of information identified above to the Recipient for the purposes stated. This authorization remains effective for the period specified above unless earlier revoked in writing.

If applicable, Subject Date of Birth:

Revocation

Discloser may revoke this Authorization at any time by providing written notice to Recipient; however, revocation will not affect disclosures made in reliance on this Authorization prior to receipt of the revocation. Specify how revocation must be delivered (optional):

Additional Provisions

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