Legal Consent Representative Letter

LEGAL CONSENT REPRESENTATIVE LETTER

This Legal Consent Representative Letter (the Letter) is made and entered into by and between Client Name: , with address: (Client), and Representative Name: of Representative Organization: , with address: (Representative), collectively the Parties, effective as of .

Recitals

WHEREAS, Client is a party to matters described as: (Matter); and

WHEREAS, Client desires to designate Representative to receive information and to act on Client's behalf for the Matter to the extent set forth in this Letter; and

WHEREAS, Representative is willing to accept such designation and to perform the duties and responsibilities described herein.

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein, and other good and valuable consideration, the Parties agree as follows.

1. Definitions

For purposes of this Letter, the following definitions apply: "Authorized Actions" means those actions described in Section 2 below; "Confidential Information" means any non-public information or records related to the Matter, including but not limited to medical, financial, legal and administrative records.

2. Appointment; Scope of Authority

Client hereby appoints Representative as Client's true and lawful representative for the Matter and grants Representative the authority to take the Authorized Actions set forth below, subject to the limitations in Section 3.

Representative is authorized to (check applicable boxes):
Receive and review documents and records related to the Matter
Execute and deliver routine documents and acknowledgments on behalf of Client, consistent with written instructions
Negotiate settlements and communications with third parties to the extent expressly authorized in writing
Obtain medical and health records relating to the Matter
Obtain financial and billing records necessary to prosecute or defend the Matter
Other authority (specify):

3. Limitations and Exclusions

The authority granted to Representative shall not include the power to make or revoke a will, to make health care decisions that require a separate power of attorney, to agree to structural settlement terms that materially affect Client's legal rights absent express prior written authorization, or to transfer, sell, or encumber Client's real property, unless expressly stated in writing. Additional limitations are set forth below.

4. Confidentiality; Consent to Disclosure

Client expressly authorizes any third party holding Confidential Information related to the Matter to disclose such information to Representative and to discuss the Matter with Representative. Client releases such third parties from any liability arising from the disclosure to Representative provided such disclosure is reasonably related to the Authorized Actions. Representative shall maintain Confidential Information in confidence and shall not disclose such information except to the extent necessary to perform Authorized Actions or as required by law.

5. Term; Revocation

This Letter shall be effective as of the Effective Date above and shall remain in effect until , or until earlier revoked by Client in accordance with this Section. Client may revoke this appointment at any time by providing written notice of revocation to Representative and to known third parties to whom Client previously granted consent, as provided in Section 6. Revocation shall be effective upon receipt by Representative or such third parties.

6. Notices

All notices, requests, consents, and other communications required or permitted under this Letter shall be in writing and delivered to the addresses provided below. Notice is effective upon personal delivery, or three (3) business days after deposit with the United States Postal Service by certified mail, return receipt requested, or upon confirmed delivery by a nationally recognized overnight courier.

7. Indemnification

Client agrees to indemnify, defend and hold harmless Representative and Representative's agents from and against any and all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising out of or relating to Representative's good-faith performance of the Authorized Actions, except to the extent such claims arise from Representative's gross negligence or willful misconduct.

8. Representations and Warranties

Each Party represents and warrants that: (a) it has full power and authority to enter into this Letter and to carry out its obligations hereunder; (b) this Letter constitutes a legal, valid and binding obligation enforceable in accordance with its terms; and (c) the execution and performance of this Letter do not violate any other agreement or legal obligation by which it is bound.

9. Governing Law

This Letter shall be governed by and construed in accordance with the laws of the state designated by Client at the time of signing: , without regard to its rules regarding conflict of laws.

10. Entire Agreement; Severability

This Letter constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior agreements, understandings and communications, whether written or oral. If any provision of this Letter is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. Amendments; Waiver; Counterparts

This Letter may be amended only by a written instrument signed by both Parties. No failure or delay by either Party in exercising any right shall operate as a waiver thereof. This Letter may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

The Parties acknowledge that they have read and understand the terms of this Letter, that they have had the opportunity to seek independent advice, and that they voluntarily accept and agree to be bound by its terms.

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