Legal Authority to Release Form

LEGAL AUTHORITY TO RELEASE FORM

This Legal Authority to Release Form (the "Authorization") is made on , by and between Releasor: Client Name: , whose address is ; and Recipient: Recipient Name: , whose address is .

RECITALS

WHEREAS, Releasor possesses certain records, files, and information identified below (the "Records") and wishes to authorize disclosure of such Records for the limited purposes set forth herein;

WHEREAS, Recipient is an entity that requires access to the Records for the purpose of ;

WHEREAS, Releasor voluntarily authorizes the release and disclosure of the Records to Recipient according to the terms and limitations of this Authorization.

NOW, THEREFORE

In consideration of the mutual covenants contained herein and other good and valuable consideration, the parties agree as follows:

1. AUTHORIZATION TO RELEASE

Releasor hereby authorizes any custodian of Records identified below to disclose and release to Recipient the Records described in Section 2. This Authorization includes the release of Records in electronic, paper and other reproducible formats and includes disclosure to Recipient's agents, employees, contractors, and representatives, solely as necessary to accomplish the Purpose.

2. SCOPE OF RECORDS TO BE RELEASED

Releasor authorizes the release of the following categories of Records (check all that apply):

Medical records and health information

Financial, bank and billing records

Employment, payroll and personnel records

Legal, litigation and case file records

Educational records and transcripts

3. LIMITATIONS AND CONDITIONS

The Recipient shall use the Records solely for the Purpose stated in this Authorization. Recipient shall not further disclose Records except as required by law or with Releasor's prior written consent. Recipient will implement and maintain reasonable administrative, technical and physical safeguards to protect the confidentiality and integrity of the Records.

4. DURATION / EXPIRATION

This Authorization becomes effective on the date set forth above and shall expire on , unless earlier revoked in writing by Releasor in accordance with Section 5. If no expiration date is provided, this Authorization will remain effective for one year from the effective date.

5. REVOCATION

Releasor may revoke this Authorization at any time by delivering a written revocation to Recipient and any known custodian of Records. Revocation is not effective to the extent that Recipient has already acted in reliance upon this Authorization or where disclosures were made pursuant to legal obligations prior to receipt of the revocation.

6. THIRD-PARTY DISCLOSURE

Recipient may share the Records with third parties only to the extent necessary to accomplish the Purpose, and only if Recipient requires such third parties to maintain confidentiality obligations at least as protective as those in this Authorization. Recipient remains responsible for any improper disclosure by such third parties.

7. INDEMNIFICATION

Releasor agrees to defend, indemnify and hold harmless Recipient and its officers, agents and employees from and against any claim, loss, liability or expense (including reasonable attorneys' fees) arising from Releasor's false statements, misrepresentations, or failure to comply with any term of this Authorization.

8. CONFIDENTIALITY AND SECURITY

Recipient shall store and handle the Records in a manner consistent with applicable confidentiality laws and shall implement reasonable safeguards to prevent unauthorized access, use, alteration, or destruction of the Records. Recipient will notify Releasor promptly upon becoming aware of any unauthorized disclosure of Records.

9. NOTICES

10. DEFINITIONS

"Records" means the categories of information identified in Section 2. "Purpose" means the purpose set forth in the recitals and in the purpose_of_release field above. "Recipient" includes Recipient's agents, contractors and representatives.

11. GOVERNING LAW

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

12. ENTIRE AGREEMENT; SEVERABILITY

This Authorization constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior oral or written agreements. If any provision of this Authorization is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

13. AMENDMENTS; WAIVER

Any amendment to this Authorization must be in writing and signed by both parties. Failure to insist on strict performance of any provision shall not be deemed a waiver of any right or remedy.

14. COUNTERPARTS; ELECTRONIC SIGNATURES

This Authorization may be executed in counterparts and delivered by electronic transmission. A signed counterpart is an original for all purposes and all counterparts together constitute one instrument.

15. CERTIFICATION

By signing below, Releasor certifies that they are the person identified above or are authorized to act on behalf of the person identified, that the information provided herein is true and correct to the best of their knowledge, and that they understand the scope, purpose and duration of this Authorization. Releasor understands that false statements may subject them to civil or criminal penalties under applicable law.

ADDITIONAL AUTHORIZED CONTACT

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