Legal Disclosure and Consent Form

LEGAL DISCLOSURE AND CONSENT FORM

This Legal Disclosure and Consent Form (Effective Date: ) is entered into by and between Discloser Name: and Recipient Name: (each a Party and together the Parties).

RECITALS

WHEREAS, Discloser possesses certain information regarding individuals, operations, and other matters that may be confidential or sensitive and that Discloser may need or desire to have disclosed or shared with Recipient for the purposes set forth below; and

WHEREAS, Recipient requires an express written authorization from Discloser to access, use, disclose or otherwise process such information for the specified purposes and agrees to the limitations and protections in this Agreement; and

WHEREAS, the Parties wish to set forth the terms under which Discloser will disclose certain categories of information and the Recipient will accept, use, protect, and (where authorized) further disclose such information.

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, the Parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, "Confidential Information" means all non-public information disclosed by Discloser to Recipient, whether oral, written, electronic or visual, that is identified as confidential or that a reasonable person would understand to be confidential under the circumstances. Confidential Information includes, without limitation, the categories selected below and any other information described in the Disclosure Description field.

Categories of Information to be disclosed (check all that apply): Personal identifiers (name, SSN, date of birth) Financial information (banking, account, credit) Medical or health information Employment and education records Other (specify):

2. DISCLOSURE DESCRIPTION AND PURPOSE

Discloser authorizes Recipient to access, obtain, receive and use the Confidential Information described below and to disclose such Confidential Information to the limited third parties set forth in Section 5 for the stated purpose(s).

3. AUTHORIZATION AND SCOPE

Discloser hereby authorizes Recipient to access, use, retain, reproduce and disclose the Confidential Information only to the extent reasonably necessary to accomplish the Purposes described in this Agreement. Recipient shall limit access to Confidential Information to those employees, agents, contractors or affiliates who have a need to know and who are bound by confidentiality obligations at least as protective as those in this Agreement.

Recipient shall not use Confidential Information for any purpose other than the Purposes expressly stated herein without the prior written consent of Discloser.

4. DURATION AND REVOCATION

This authorization shall remain in effect until: or until revoked in writing by Discloser. Revocation shall be effective upon receipt by Recipient of written notice at the addresses specified in Section 9, except to the extent Recipient has already relied on this authorization or made disclosures prior to receipt of the revocation.

5. THIRD PARTIES AND REDISCLOSURE

Recipient may disclose Confidential Information to third parties only for the Purposes set forth in this Agreement and only to the extent Recipient has a written agreement with such third parties requiring confidentiality obligations no less protective than those contained herein. A non-exhaustive list of authorized third parties follows.

6. CONFIDENTIALITY, SECURITY AND COMPLIANCE

Recipient shall implement and maintain administrative, technical and physical safeguards reasonably designed to protect the confidentiality, integrity and availability of Confidential Information. Recipient will comply with all applicable laws and regulations governing the privacy and protection of the Confidential Information.

In the event of an unauthorized use or disclosure of Confidential Information, Recipient shall promptly notify Discloser and take all reasonable steps to mitigate the effects of the unauthorized use or disclosure.

7. ACKNOWLEDGMENTS AND CONSENT

By signing below, Discloser acknowledges that Discloser has read and understands the scope and effect of this consent and authorizes the disclosure and use described herein. Recipient acknowledges its obligations to protect Confidential Information and to use such information only for the authorized Purposes.

8. FEES

Unless separately agreed in writing, there shall be no fee to execute this Authorization. If Discloser will be charged for copies or processing, such fees will be communicated and agreed in writing prior to any charge.

9. NOTICES

All notices, requests, demands, and other communications under this Agreement shall be in writing and delivered to the contact information provided below.

10. AMENDMENT; WAIVER; COUNTERPARTS

This Agreement may not be amended except by a written instrument signed by both Parties. No waiver of any provision shall be effective unless in writing and signed by the waiving Party. This Agreement may be executed in counterparts and delivered by electronic transmission, each of which shall be deemed an original.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

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

This Agreement constitutes the entire agreement between the Parties with respect to its subject matter and supersedes all prior and contemporaneous agreements and understandings, whether written or oral.

If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. MISCELLANEOUS

The Parties represent and warrant that they have the authority to enter into this Agreement. Nothing in this Agreement shall be construed to limit any rights or remedies that a Party may have under applicable law.

Sign Now