Legal Authorization to Release Information

LEGAL AUTHORIZATION TO RELEASE INFORMATION

This Authorization to Release Information ("Authorization") is entered into on Effective Date: by and between Authorizing Party: whose address is and Recipient: whose address is .

RECITALS

WHEREAS, Authorizing Party is a person or entity who possesses or controls certain confidential records and information concerning the Authorizing Party's affairs; and

WHEREAS, the Provider or holder of records is: , located at , which retains or controls the records subject to this Authorization; and

WHEREAS, Authorizing Party desires to permit disclosure of specified information to Recipient for the limited purposes stated below.

NOW THEREFORE, in consideration of the mutual covenants and promises contained herein, and other good and valuable consideration, the parties agree as follows:

1. DEFINITIONS

For purposes of this Authorization: "Provider" means the person or entity identified in the Recitals who maintains the records; "Recipient" means the person or entity identified above; "Information" means the records and data described in Section 2 below.

2. SCOPE OF AUTHORIZATION

Authorizing Party hereby authorizes Provider to disclose the following categories of Information to Recipient (check all that apply):

3. PURPOSE OF DISCLOSURE

The Information shall be disclosed to Recipient for the following specific purpose(s):

4. AUTHORIZATION TO RELEASE SPECIFIC INFORMATION

Provider is authorized to disclose copies of records, summaries, and any oral disclosures reasonably necessary to accomplish the Purpose. This includes records prepared by third parties in Provider's possession. If the Authorizing Party intends to permit release of psychotherapy notes, check the box and describe:

5. DURATION AND EXPIRATION

This Authorization is effective immediately upon signature and shall expire on: unless revoked earlier in accordance with Section 6.

6. REVOCATION

Authorizing Party may revoke this Authorization at any time by delivering a written notice of revocation to Provider and to Recipient. Revocation will not affect disclosures made in reliance upon this Authorization prior to receipt of a valid revocation. Revocation is not effective to the extent that Provider has already acted in reliance on this Authorization or to the extent that this Authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7. REDISCLOSURE

Recipient is advised that once Information is disclosed it may be subject to further disclosure by Recipient and may no longer be protected by applicable privacy laws. Recipient shall make reasonable efforts not to redisclose Information except as permitted by law or with further authorization. Recipient agrees to restrict use of Information to the Purpose and to safeguard Information against unauthorized use or disclosure.

8. FEES AND COSTS

Provider may charge reasonable fees for copying, reproduction and postage. If fees are to be limited or waived, indicate here:

9. REPRESENTATIONS AND AUTHORITY

Authorizing Party represents that they are the subject of the Information or otherwise have the legal authority to authorize disclosure of the Information. Authorizing Party agrees to indemnify Recipient and Provider for claims arising from any misrepresentation of authority made by Authorizing Party.

10. LIMITATIONS

This Authorization is limited to the specific Information and Purpose stated herein. It does not authorize release of Information beyond that which is reasonably necessary to accomplish the Purpose. This Authorization does not waive any rights Authorizing Party has under applicable statutes, except as expressly set forth.

11. NOTICES

All notices under this Authorization shall be in writing and delivered to the addresses set forth above or to such other address as a party may designate in writing. Notice is effective upon personal delivery or three (3) business days after deposit in the United States mail, postage prepaid, addressed to the designated address.

12. GENERAL PROVISIONS

Governing Law: This Authorization shall be governed by and construed in accordance with the laws of the state identified for the Recipient's address or, if no state is identifiable, the state wherein Provider maintains records.

Entire Agreement: This Authorization constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous oral or written agreements concerning the same subject.

Severability: If any provision of this Authorization is held invalid or unenforceable, the remaining provisions shall continue in full force and effect to the extent permitted by law.

Amendments; Waiver: This Authorization may be amended only by a written instrument executed by both parties. No waiver of any breach or default shall be deemed a waiver of any subsequent breach or default.

Counterparts: This Authorization may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. A facsimile or electronic image of a signature shall be deemed an original signature for all purposes.

CERTIFICATION

By signing below, Authorizing Party certifies that they have read and understand this Authorization, that the information provided is true and correct to the best of their knowledge, and that they voluntarily authorize the release of the Information as specified herein.

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