Legal Consent to Release

LEGAL CONSENT TO RELEASE

This Legal Consent to Release (the Consent) is made as of the Effective Date set forth below by and between Releasor Name: with address: ("Releasor"), and Recipient Name: with address: ("Recipient").

RECITALS

WHEREAS, Releasor possesses certain records, information and documentation, including but not limited to personal, medical, employment, financial, educational and other records, which Releasor may authorize to be disclosed to Recipient; and

WHEREAS, Recipient has requested access to certain such records for the purpose set forth below and Releasor is willing to authorize disclosure of the specified information under the terms and conditions of this Consent; and

WHEREAS, Releasor understands that this Consent is a legal authorization permitting disclosure of protected information as described herein.

NOW, THEREFORE, in consideration of the mutual promises contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Consent, "Released Information" means any and all data, records, reports, notes, correspondence, and electronic files identified in Section 3 that pertain to Releasor and that are in the possession or control of any third party custodian. "Recipient" includes Recipient and Recipient's agents, representatives, attorneys, insurers, third party contractors and assigns.

2. CONSENT TO RELEASE

Releasor hereby authorizes and directs any person, institution, employer, medical provider, insurer, school, government agency, or other custodian of records to disclose and furnish to Recipient the Released Information described in Section 3. This authorization permits the disclosure of Released Information regardless of whether such information would otherwise be protected by law, to the extent permitted by applicable law.

3. SCOPE OF INFORMATION TO BE RELEASED

If no limitations are specified above, this Consent authorizes the release of all records lawfully disclosable to Recipient.

4. PURPOSE OF DISCLOSURE

5. DURATION

This Consent shall become effective on the Effective Date: , and shall remain in effect until: , unless earlier revoked in writing by Releasor pursuant to applicable law.

6. REVOCATION

Releasor may revoke this Consent at any time by delivering written notice of revocation to Recipient and to any known custodian of Released Information. Revocation shall not affect disclosures already made in reliance on this Consent prior to receipt of such revocation, if such disclosures were made in good faith and in accordance with this Consent.

7. CONFIDENTIALITY AND USE LIMITATIONS

Recipient shall use the Released Information only for the Purpose stated in Section 4 and shall not disclose such information to third parties except as permitted by this Consent or compelled by law. Recipient shall implement reasonable administrative, technical and physical safeguards to protect Released Information from unauthorized access or disclosure.

8. INDEMNIFICATION

To the extent permitted by applicable law, Releasor shall indemnify, defend and hold harmless Recipient and its agents from and against any claims, liabilities, losses or damages arising from misstatements, omissions or inaccuracies in the information provided by Releasor to Recipient in connection with this Consent, except where such claims arise from Recipient's willful misconduct or breach of this Consent.

9. LIMITATION OF LIABILITY

Except as expressly provided herein, neither party shall be liable to the other for incidental, consequential, punitive or special damages arising from the performance or nonperformance of obligations under this Consent, whether in contract, tort or otherwise, except for liability arising from a party's gross negligence or willful misconduct.

10. NOTICES

All notices required or permitted under this Consent shall be in writing and provided to the addresses set forth in the opening paragraph or to such other address as a party designates in writing. Notices shall be deemed given when delivered personally or three (3) business days after deposit in the U.S. mail, postage prepaid, or upon confirmed electronic delivery to an address previously agreed in writing.

11. AMENDMENT; WAIVER; COUNTERPARTS

This Consent may be amended or modified only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing signed by the party against whom enforcement is sought. This Consent 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.

12. GOVERNING LAW; JURISDICTION

This Consent shall be governed by and construed in accordance with the laws of the state governing the agreement between the parties as reflected by the parties' primary addresses, without regard to conflict of law principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in the governing jurisdiction for resolution of disputes arising out of or related to this Consent.

13. ENTIRE AGREEMENT; SEVERABILITY

This Consent constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and representations, whether oral or written. If any provision of this Consent is held invalid or unenforceable, the remaining provisions shall continue in full force and effect to the extent permitted by law.

14. REPRESENTATIONS AND WARRANTIES

Releasor represents and warrants that Releasor has the full legal capacity and authority to execute this Consent and to authorize the release of the Released Information described herein. If executed by an authorized representative, the person signing warrants that he or she has the authority to sign on behalf of the Releasor and to bind the Releasor to the terms of this Consent.

15. VOLUNTARY CONSENT

By checking the box below, Releasor certifies that Releasor has read and understands this Consent, that Releasor has had the opportunity to ask questions regarding the scope and purpose of the release, and that the Consent is given voluntarily and without coercion.

I acknowledge and provide voluntary consent for the release described in this Consent.

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