Legal Access Authorization Form

LEGAL ACCESS AUTHORIZATION FORM

This Legal Access Authorization Form (the "Authorization") is entered into as of Effective Date: by and between Client Name: (hereinafter "Principal") and Authorized Representative Name: (hereinafter "Authorized Representative").

RECITALS

WHEREAS, Principal is a party to certain legal matters and maintains records, files and information relevant to those matters; and

WHEREAS, Principal desires to grant Authorized Representative limited authority to access, inspect, copy and receive information and documents on Principal's behalf as set forth in this Authorization; and

WHEREAS, Authorized Representative agrees to act in accordance with the limitations and duties set forth herein.

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

1. AUTHORIZATION

Principal hereby authorizes Authorized Representative to request, obtain, inspect and receive copies of legal records, case files, correspondence, pleadings, settlement documents, and related materials (collectively "Records") from attorneys, courts, governmental agencies, custodians of records, financial institutions, medical providers, and other third parties as necessary to represent or assist Principal in the matters identified in Section 2. This Authorization includes authority to receive service of process and to accept notices on behalf of Principal only where expressly indicated in writing.

2. SCOPE OF ACCESS

The authorization granted hereunder applies to the following matters and categories of records. Select all categories to be authorized:

Matters to which this Authorization Applies:

Case files and court documents
Medical records and provider communications
Financial records, bank statements, and billing information
Correspondence with counsel, opponents, or third parties
Other (specify in Additional Instructions)

Additional Instructions or Limitations:

3. TERM

This Authorization is effective beginning on Effective Date: and shall expire on Expiration Date: unless earlier revoked in accordance with Section 7.

4. DUTIES, LIMITATIONS AND REPRESENTATIONS

Authorized Representative shall act only within the scope expressly granted herein, shall not settle claims on behalf of Principal unless separately authorized in writing, and shall not disclose confidential information except as necessary to obtain Records or to provide legal services to Principal. Authorized Representative represents that they are authorized and legally able to accept and handle such Records in compliance with applicable professional, statutory and ethical obligations.

5. CONFIDENTIALITY AND USE OF RECORDS

Authorized Representative shall maintain the confidentiality of all Records and shall use such Records solely for the purposes set forth in this Authorization. Disclosure is permitted only to attorneys, agents, service providers or others who need access to fulfill the purposes of this Authorization and who are bound by confidentiality obligations no less protective than those herein.

6. THIRD-PARTY RELIANCE

Principal authorizes third parties to rely upon and comply with this Authorization. Third parties that provide Records in good faith reliance on this Authorization shall have no liability to Principal or Authorized Representative for such disclosure. Principal agrees to execute any additional authorizations reasonably requested by third parties to effectuate the release of Records.

7. REVOCATION

Principal may revoke this Authorization at any time by providing written notice to Authorized Representative and to third parties to whom access has been granted. Revocation shall not affect disclosures made in good faith prior to actual receipt of notice of revocation.

8. INDEMNIFICATION

Principal agrees to indemnify, defend and hold harmless Authorized Representative and any third party who acts in reasonable reliance on this Authorization from and against any liability, loss or expense (including reasonable attorneys' fees) arising from any claim, demand or action related to the lawful disclosure or use of Records pursuant to this Authorization, except to the extent caused by Authorized Representative's gross negligence or willful misconduct.

9. NOTICES

Any notice required or permitted under this Authorization must be sent to the addresses provided below and shall be effective upon receipt.

10. AMENDMENT; WAIVER

No amendment, modification or waiver of any provision of this Authorization shall be effective unless made in writing and signed by both parties. No failure or delay by any party in exercising any right shall operate as a waiver of that right.

11. GOVERNING LAW

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

12. ENTIRE AGREEMENT

This Authorization constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations and understandings, whether written or oral, relating thereto.

13. SEVERABILITY

If any provision of this Authorization is determined to be invalid or unenforceable, the remaining provisions shall remain in full force and effect and shall be construed so as to effectuate the parties' intent to the greatest extent permitted by law.

14. COUNTERPARTS

This Authorization may be executed in one or more counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures transmitted by electronic means shall be deemed original signatures for all purposes.

IDENTIFICATION

Identification Documents Provided (type and number):

Principal Date of Birth:    Identification Number (last 4 digits if applicable):

By signing below, Principal certifies that they are the person named above, that they have read and understood this Authorization, and that they voluntarily grant the permissions described herein. Authorized Representative acknowledges receipt of this Authorization and agrees to act in accordance with its terms.

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