Legal Data Authorization Form

LEGAL DATA AUTHORIZATION FORM

This Legal Data Authorization Form (the Authorization) is entered into as of by and between Data Subject: of (Data Subject), and Data Holder: of (Data Holder). The Data Subject hereby authorizes the disclosure of certain personal data to Recipient: at (Recipient).

RECITALS

WHEREAS, Data Subject is an individual whose personal data is maintained, possessed or controlled by Data Holder; and

WHEREAS, Data Subject desires to authorize Data Holder to disclose specified categories of personal data to the Recipient for the Purpose described below; and

WHEREAS, Data Holder agrees to disclose such data only in accordance with the terms and conditions set forth in this Authorization.

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

1. DEFINITIONS

1.1 "Authorized Data" means the categories of information described in Section 2 below that Data Subject expressly authorizes Data Holder to disclose to Recipient.

1.2 "Purpose" means the specific purpose for disclosure identified by Data Subject in Section 3 and limited to the uses described herein.

2. AUTHORIZED DATA

Data Subject specifically authorizes disclosure of the following categories of data (select applicable categories):

3. PURPOSE AND SCOPE

The disclosure authorized by Data Subject is limited to information reasonably necessary to accomplish the Purpose. Recipient shall use Authorized Data solely for the Purpose and shall not further process, sell, or disclose such data except as expressly permitted by this Authorization or required by law.

4. METHOD AND FORMAT OF DISCLOSURE

Data Holder may disclose Authorized Data to Recipient by secure electronic transmission, encrypted file transfer, secure portal access, or by physical delivery of records. Any transmission shall employ reasonable safeguards appropriate to the sensitivity of the data, including encryption where technically feasible.

5. DURATION AND REVOCATION

This Authorization shall become effective on the Effective Date identified above and shall remain in effect until unless earlier revoked in writing by Data Subject pursuant to this Section.

Revocation must be delivered in writing to the Data Holder at the Notice Address specified in Section 11. Revocation shall be effective only upon receipt by Data Holder; disclosures made prior to receipt shall remain lawful and are not affected by revocation.

6. CONFIDENTIALITY AND SECURITY

Recipient agrees to implement and maintain administrative, technical, and physical safeguards reasonably designed to protect Authorized Data from unauthorized access, use, disclosure, alteration, or destruction. Recipient shall notify Data Holder promptly upon becoming aware of any unauthorized disclosure or security breach involving Authorized Data and shall cooperate in mitigation.

7. LIMITATIONS ON REDISCLOSURE

Recipient shall not sell, transfer, or disclose Authorized Data to any third party except (a) with Data Subject's prior written consent, (b) to agents or subcontractors bound by written obligations consistent with this Authorization, or (c) as required by law, in which event Recipient shall notify Data Holder and Data Subject if permitted.

8. REPRESENTATIONS AND WARRANTIES

Data Subject represents that he or she has the legal capacity and authority to execute this Authorization. Data Holder represents that it has authority to disclose the Authorized Data described herein. Each party warrants that it will comply with applicable data protection and privacy laws in performing its obligations under this Authorization.

9. INDEMNIFICATION AND LIMITATION OF LIABILITY

Recipient shall indemnify and hold harmless Data Subject and Data Holder from and against any third-party claims, liabilities, losses, costs and expenses (including reasonable attorneys' fees) arising from Recipient's unauthorized use or disclosure of Authorized Data. Except for willful misconduct or gross negligence, neither Data Holder nor Recipient shall be liable for incidental or consequential damages.

10. COMPLIANCE WITH LAWS

Each party shall comply with all applicable laws, regulations and rules governing the collection, use, storage and disclosure of personal data, including but not limited to data protection and privacy statutes applicable to the jurisdiction identified in Section 14.

11. NOTICES

All notices, requests, consents, claims, demands, waivers and other communications hereunder shall be in writing and addressed to the parties at the addresses set forth below or to such other address that a party may designate in writing.

12. AMENDMENT, WAIVER AND COUNTERPARTS

This Authorization may be amended or modified only by a written instrument signed by both Data Subject and Data Holder. No failure or delay by any party in exercising any right shall be deemed a waiver of that right. This Authorization may be executed in counterparts, each of which shall be deemed an original.

13. ENTIRE AGREEMENT; SEVERABILITY; GOVERNING LAW

This Authorization constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings. If any provision of this Authorization is held to be invalid, illegal or unenforceable, the remaining provisions shall continue in full force and effect. The validity, interpretation and performance of this Authorization shall be governed by the laws of the jurisdiction identified below.

14. DATA SUBJECT DETAILS

15. ACKNOWLEDGMENTS AND CONSENT

By signing below, Data Subject acknowledges that he or she has read and understands this Authorization, that the Authorization is voluntary, and that Data Subject may revoke this Authorization in writing as provided in Section 5. Data Subject understands that disclosures made in reliance on this Authorization prior to revocation may not be retractable.

Data Subject further acknowledges that certain information designated as sensitive (for example, medical or financial data) will be released only if expressly selected in Section 2, and that such selection constitutes express written consent for disclosure of such sensitive information.

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