Legal MCAP Consent Form

LEGAL MCAP CONSENT FORM

This MCAP Consent Form (the "Consent") is entered into as of by and between Participant Name: with address (hereinafter "Participant"), and MCAP Administrator Name: with address (hereinafter "Administrator"). Participant and Administrator are each a "Party" and together the "Parties."

RECITALS

WHEREAS, Administrator administers the Multi-Claim Access Program ("MCAP"), a program under which certain information may be collected, shared, and used for the purposes set forth herein; and

WHEREAS, Participant desires to participate in MCAP and to grant Administrator and designated third parties the limited rights to access and use Participant's records and information as described in this Consent; and

WHEREAS, Administrator requires a signed consent and specific authorizations from Participant to obtain, disclose, and process Participant's information under the terms and conditions of this Consent.

NOW, THEREFORE, in consideration of the mutual promises and covenants set forth below, and for 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 have the meanings set forth below:

"Authorized Purposes" means the purposes described in Section 3, including enrollment, eligibility verification, claims processing, program administration, coordination of services, and quality assurance.

"Protected Information" means any records, documents, communications, or data concerning Participant, whether in written, electronic, or other form, including but not limited to medical records, claims and billing information, financial records, and legal documents, as authorized below.

2. GRANT OF CONSENT

Participant hereby grants Administrator and Administrator's designees a limited, revocable consent to obtain, access, use, disclose and exchange Protected Information for the Authorized Purposes described herein. This consent expressly includes the collection and sharing of the categories of information indicated by Participant below:

Medical records (history, treatment records)
Claims and billing records
Financial records related to program eligibility
Legal, adjudicative, or administrative records
Other (describe):

3. SCOPE AND PURPOSE OF AUTHORIZATION

The authorization granted by Participant permits Administrator to: (a) obtain Protected Information from healthcare providers, payors, governmental agencies, and other custodians of records; (b) disclose Protected Information to program partners, contractors, and affiliates to the extent necessary to effectuate the Authorized Purposes; and (c) retain and process Protected Information in electronic or physical form. Authorized Purposes shall include program enrollment, determining eligibility, coordinating services, verifying claims, evaluating program performance, and conducting audits and quality reviews.

4. METHODS OF DISCLOSURE AND PROTECTIONS

Administrator shall use reasonable administrative, technical, and physical safeguards to protect Protected Information from unauthorized access, disclosure, alteration, or destruction. Disclosures permitted under this Consent may be made verbally, in writing, or by secure electronic transfer. Administrator will only disclose the minimum necessary information to accomplish the Authorized Purposes.

5. DURATION AND REVOCATION

This Consent shall be effective as of the date set forth above and shall continue in effect until or until revoked by Participant in writing. Revocation does not affect disclosures already made in reliance on this Consent prior to receipt of a valid revocation.

6. REPRESENTATIONS AND WARRANTIES

Participant represents and warrants that Participant has the legal authority to execute this Consent and to authorize the disclosure of the Protected Information identified herein. Administrator represents that it will only use and disclose Protected Information in accordance with this Consent and applicable law.

7. INDEMNIFICATION

Participant agrees to defend, indemnify and hold harmless Administrator and its officers, directors, employees, agents and contractors from and against any and all claims, liabilities, losses, damages and expenses (including reasonable attorneys' fees) arising out of Participant's breach of this Consent, any false representation by Participant, or any unauthorized disclosure initiated by Participant.

8. LIMITATION OF LIABILITY

EXCEPT FOR LIABILITY ARISING FROM WILLFUL MISCONDUCT OR GROSS NEGLIGENCE, NEITHER PARTY SHALL BE LIABLE TO THE OTHER FOR INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, OR PUNITIVE DAMAGES ARISING OUT OF OR RELATING TO THIS CONSENT, WHETHER IN CONTRACT, TORT, OR OTHERWISE.

9. CONFIDENTIALITY; DATA SECURITY

Administrator shall implement and maintain appropriate safeguards to protect the confidentiality and integrity of Protected Information. Administrator will promptly notify Participant upon discovery of any unauthorized access to or disclosure of Protected Information that materially compromises Participant's privacy, and will cooperate with Participant in any mitigation efforts.

10. NOTICES

All notices, requests, and other communications required or permitted under this Consent shall be in writing and delivered to the addresses below by personal delivery, certified mail (return receipt requested), or nationally recognized overnight courier:

11. AMENDMENTS AND WAIVER

This Consent may be amended or modified only by a written instrument executed by both Parties. No waiver of any provision shall be effective unless in writing and signed by the Party granting the waiver. A waiver of any breach shall not constitute a waiver of any subsequent breach.

12. GOVERNING LAW

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

13. ENTIRE AGREEMENT

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

14. 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 be affected or impaired.

15. COUNTERPARTS

This Consent may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Electronic signatures, including scanned or electronic images of signatures, shall be binding and enforceable.

16. ACKNOWLEDGMENT

Participant acknowledges that Participant has read this Consent, understands its terms, and has had the opportunity to ask questions prior to signing. Participant further acknowledges receipt of a copy of this Consent.

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