Legal Information Consent Form

LEGAL INFORMATION CONSENT FORM

This Legal Information Consent Form (the "Consent") is entered into as of Effective Date: by and between Client Name: whose address is and Recipient Name: whose address is .

RECITALS

WHEREAS, Client has legal, administrative or personal information that may be relevant to matters for which Recipient will provide services or act on behalf of Client; and

WHEREAS, Client desires to authorize the disclosure of certain designated information to Recipient for the limited purposes set forth below, and Recipient desires to receive and use such information subject to the terms and conditions of this Consent; and

WHEREAS, the parties intend by this Consent to establish the scope, duration and safeguards for disclosure and subsequent use of Client's information.

NOW THEREFORE, in consideration of the mutual promises herein contained 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, the following terms shall have the meanings set forth below: "Information" means any written, electronic, oral or other material regarding Client, including without limitation case files, records, communications, medical records, financial records, employment records, and other data identified in Section 3; "Disclosing Party" means Client; and "Receiving Party" means Recipient.

2. SCOPE OF CONSENT

Client hereby authorizes Recipient to receive, review and reproduce the Information described in Section 3 for the limited Purpose described in Section 4. This authorization extends only to those persons within Recipient's organization who have a need to know the Information to accomplish the Purpose, and does not authorize broader dissemination except as expressly provided herein.

3. AUTHORIZED INFORMATION

The Information authorized for disclosure includes the following categories (check all that apply) and any specific documents described in the accompanying text:

Case files and legal pleadings Medical records and health information Financial records, bank statements and tax documents Communications with counsel, advisors or third parties

4. PURPOSE

The Information shall be disclosed and used solely for the following purpose(s): . Recipient shall not use the Information for any unrelated purpose without the prior written consent of Client.

5. DURATION, REVOCATION AND EFFECT OF TERMINATION

This Consent shall remain in effect until Expiration Date: unless earlier revoked in writing by Client. Revocation shall be effective upon actual receipt by Recipient of written notice of revocation at the address specified in Section 12; provided, however, that revocation shall not affect disclosures made in good faith prior to receipt of such notice.

6. CONFIDENTIALITY; RESTRICTIONS ON USE

Recipient shall treat all Information as confidential and shall not disclose, publish, distribute or otherwise make available any Information to any third party except as expressly permitted by this Consent or as required by operation of law. Recipient shall use at least the same degree of care to protect the Information as it uses to protect its own confidential information, but in no event less than reasonable care.

7. THIRD-PARTY DISCLOSURE

If Recipient determines that disclosure to a third party is necessary to accomplish the Purpose, Recipient must obtain Client's prior written consent unless disclosure is compelled by legal process. If disclosure is compelled, Recipient shall provide Client with prompt written notice of such process to the extent permitted by law.

8. DATA SECURITY

Recipient shall implement and maintain administrative, physical and technical safeguards appropriate to the sensitivity of the Information to prevent unauthorized use, access, disclosure, alteration or destruction, including secure transmission protocols and access controls for electronic data and secure storage for physical records.

9. REPRESENTATIONS AND WARRANTIES

Each party represents and warrants that it has the full right and authority to enter into this Consent and that the execution and performance of this Consent will not violate any applicable law or agreement of such party. Client represents that the consent provided herein is voluntarily given by the person executing this Consent on Client's behalf.

10. INDEMNIFICATION

Recipient shall indemnify, defend and hold harmless Client and its officers, directors, agents and employees from and against any and all claims, losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising out of Recipient's unauthorized disclosure or improper use of the Information in violation of this Consent.

11. LIMITATION OF LIABILITY

EXCEPT FOR LIABILITY ARISING FROM WILLFUL MISCONDUCT OR GROSS NEGLIGENCE, NEITHER PARTY SHALL BE LIABLE TO THE OTHER FOR CONSEQUENTIAL, INCIDENTAL, SPECIAL OR PUNITIVE DAMAGES ARISING OUT OF THIS CONSENT, REGARDLESS OF WHETHER SUCH PARTY HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.

12. NOTICES

All notices, requests, consents and other communications required or permitted hereunder shall be in writing and shall be delivered to the parties at the addresses specified below (or such other addresses as a party may designate by notice to the other):

13. AMENDMENTS; WAIVER; COUNTERPARTS

This Consent may be amended only by a writing signed by both parties. No waiver of any right or remedy under this Consent shall constitute a waiver of any other right or remedy. This Consent may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

14. GOVERNING LAW

This Consent shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles.

15. ENTIRE AGREEMENT

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 communications, whether written or oral, concerning the same.

16. SEVERABILITY

If any provision of this Consent is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired.

17. SIGNATURES

The individuals signing below represent and warrant that they are authorized to execute this Consent on behalf of the party for which they sign.

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