Legal Attorney ROI Template

LEGAL ATTORNEY RELEASE OF INFORMATION (ROI) TEMPLATE

This Release of Information Agreement ("Agreement") is made and entered into on by and between Authorizing Party: , whose address is (hereafter "Authorizing Party"), and Recipient/Attorney: , representing , with address (hereafter "Recipient").

RECITALS

WHEREAS, Authorizing Party seeks to permit disclosure of certain records and information maintained by a third-party custodian identified as ;

WHEREAS, Recipient requires access to specified records for the legitimate purpose described below and will use such records in connection with (Matter);

WHEREAS, Authorizing Party is the individual or authorized representative with authority to direct disclosure of the records described in this Agreement.

NOW, THEREFORE

In consideration of the mutual covenants set forth herein, and other good and valuable consideration, the sufficiency of which is hereby acknowledged, the parties agree as follows:

1. AUTHORIZATION

Authorizing Party hereby authorizes any custodian of records, including but not limited to , to disclose the records and information described in Section 2 to Recipient, its agents, representatives, counsel and insurers, for use in the Matter. This authorization includes release in electronic, paper and summary form where applicable.

2. SCOPE OF RECORDS

The records to be disclosed are limited to the following categories (check all applicable):

Medical records Mental health/psychotherapy notes Legal/Case files

Employment records Financial/tax records Entire record held by custodian

3. PURPOSE

4. DURATION; REVOCATION

This authorization shall be effective beginning on and shall expire on , unless earlier revoked in writing. Revocation must be delivered in writing to the custodian of records and to Recipient at the notice address in Section 8, and shall not apply to disclosures already made in reliance on this authorization prior to receipt of the revocation.

5. FEES AND CHARGES

Authorizing Party agrees to reimburse the custodian for reasonable copying, handling and postage charges in accordance with the custodian's standard fees. Notwithstanding the foregoing, the maximum aggregate fee the Authorizing Party authorizes without further written consent is $.

6. CONFIDENTIALITY; REDISCLOSURE

Recipient acknowledges that the records received under this Agreement may contain confidential or privileged information. Recipient agrees to maintain the confidentiality of such records to the fullest extent permitted by law. Recipient shall not disclose records received hereunder to any third party except as required to prosecute or defend the Matter, or as otherwise required by law, and shall provide notice to Authorizing Party prior to any compelled disclosure where possible.

7. LIABILITY; INDEMNIFICATION

Authorizing Party releases and holds harmless the custodian for disclosures made in good faith pursuant to this authorization. Recipient shall indemnify and defend Authorizing Party from and against any third-party claims arising from Recipient's unauthorized use or further disclosure of the records, except to the extent caused by the custodian's gross negligence or willful misconduct.

8. NOTICES

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of laws principles. This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior statements, negotiations and understandings. If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment, modification or waiver of any provision of this Agreement shall be effective unless in writing and executed by both parties. Failure to enforce any provision shall not constitute a waiver of that provision. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together constitute one instrument.

11. CERTIFICATION

Authorizing Party certifies that the information provided in this Agreement is true and correct to the best of their knowledge, that they are authorized to execute this authorization, and that the disclosure authorized herein is voluntary. Authorizing Party understands that they may request a copy of this signed authorization.

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