Legal Authority To Disclose Form

LEGAL AUTHORITY TO DISCLOSE FORM

This Legal Authority to Disclose (the "Authority") is entered into by and between Client Name: residing at (referred to herein as "Client"), and Authorized Recipient Name: of (referred to herein as "Recipient"), effective as of the date of signature below.

RECITALS

WHEREAS, Client possesses certain confidential and potentially protected information concerning Client or a third party identified below; and

WHEREAS, Client desires to authorize disclosure of such specified information to Recipient for the limited purposes described herein; and

WHEREAS, Recipient agrees to receive, use, and protect such information in accordance with the terms and limitations set forth in this Authority.

NOW, THEREFORE

In consideration of the mutual covenants and promises contained herein, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. AUTHORIZATION

Client hereby authorizes any person, entity, or institution in possession of the Client's information, including but not limited to health care providers, financial institutions, employers, educational institutions, and legal counsel ("Disclosing Parties"), to disclose to Recipient the types of information identified in Section 2 below. This authorization extends only to the specific information and purposes set forth in this Authority and does not constitute a blanket authorization for disclosure of unrelated records.

2. SCOPE OF INFORMATION

The categories of information authorized for disclosure are limited to the following (check all applicable categories and describe any limitations):

3. PURPOSE OF DISCLOSURE

The disclosure authorized herein is for the following purpose(s):

4. DURATION

This Authority shall become effective on and shall remain effective until unless revoked earlier in accordance with Section 5. If no termination date is specified, this Authority shall expire one year from the effective date or as otherwise required by applicable law.

5. REVOCATION

Client may revoke this Authority at any time by providing written notice of revocation to Recipient and to the Disclosing Parties. Revocation shall not apply to disclosures already made in reliance on this Authority prior to receipt of the revocation. To be effective, revocation must be signed and dated by the Client and delivered to Recipient at the Notices address in Section 10.

6. LIMITATIONS AND CONDITIONS

Client represents and warrants that Client has the authority to authorize the disclosure of the information described herein. If the information concerns another individual, Client attests to having appropriate legal authority to execute this Authorization on that individual's behalf and provides the subject's name if different from Client:

Disclosure of substance use disorder records, psychotherapy notes, HIV-related information, or other specially protected categories requires explicit notation below. Check each special category authorized for disclosure:

7. REDISCLOSURE AND CONFIDENTIALITY

Recipient acknowledges that information disclosed under this Authority may be confidential or protected by law. Recipient shall use reasonable safeguards to protect the confidentiality of disclosed information and shall not redisclose such information except as permitted by law or with prior written consent of Client. Any unintended redisclosure by Recipient shall be reported immediately to Client and, where applicable, to the original Disclosing Party.

8. COSTS AND FEES

Client agrees to reimburse Disclosing Parties or Recipient for reasonable copying, retrieval, or administrative fees incurred in providing disclosed records, unless otherwise prohibited by law. Any preconditions for providing records, including payment arrangements, shall be specified in writing between Client and the Disclosing Party.

9. NOTICES

All notices, requests for revocation, or other communications under this Authority shall be in writing and delivered to the addresses set forth below:

10. REPRESENTATIONS, WARRANTIES, AND CERTIFICATION

Client represents that the information provided in this Authority is true and correct, that Client is lawfully authorized to permit the release of the information specified, and that Client understands the nature and consequences of this Authorization. Client further certifies that any third-party subject named herein has authorized Client to act on their behalf when applicable.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Authority shall be governed by and construed in accordance with the laws of the jurisdiction in which the Recipient maintains its principal place of business, without regard to conflict of laws principles. This document constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior oral or written agreements relating to the same. If any provision of this Authority is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. AMENDMENT; WAIVER; COUNTERPARTS

This Authority may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party against whom enforcement is sought. This Authority may be executed in counterparts, each of which shall be deemed an original, and facsimile or electronic signatures shall be treated as originals for all purposes.

13. ACKNOWLEDGEMENT OF UNDERSTANDING

By signing below, Client acknowledges that Client has read and understands this Authority, that Client's authorization is voluntary, and that Client may request and receive a copy of this signed form.

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