Legal Privacy Authority Form

LEGAL PRIVACY AUTHORITY FORM

This Legal Privacy Authority Form (the "Form") is entered into as of by and between Principal Name: Principal Address: and Authorized Representative Name: Authorized Representative Address:

RECITALS

WHEREAS, Principal possesses certain personal, financial, health, employment or other confidential information, records and data (collectively, "Protected Information") and desires to permit Authorized Representative to access and act upon such Protected Information on Principal's behalf as set forth herein;

WHEREAS, Authorized Representative represents that it has the competence, authority and lawful need to obtain, use and disclose such Protected Information for the purposes described below and agrees to safeguard and restrict its use to those purposes; and

WHEREAS, Principal and Authorized Representative wish to record the scope, duration and conditions of the authority granted to ensure compliance with applicable privacy laws and contractual obligations.

NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth below, Principal hereby grants to Authorized Representative the authority described in this Form, subject to the terms and limitations herein.

1. GRANT OF AUTHORITY

Principal hereby authorizes Authorized Representative to request, receive, access, inspect, copy, and otherwise obtain or handle Protected Information from any third party, data holder, custodian or service provider, and to take such acts as necessary to effectuate the purposes described below. This authority includes the right to execute releases, consents, verifications, administrative authorizations, and other documents on behalf of Principal to obtain Protected Information, provided that such documents are reasonably necessary and consistent with this Form.

2. PURPOSE AND SCOPE

The authority granted hereunder is limited to the following purposes: . Principal expressly limits Authorized Representative's use of Protected Information to activities that are reasonably necessary to accomplish these stated purposes.

3. DURATION; REVOCATION

This authority commences on the effective date set forth above and continues until: unless earlier revoked in writing by Principal. Revocation shall be effective upon actual receipt by Authorized Representative or any third party that has received a copy of this Form from Authorized Representative.

4. DUTIES, LIMITATIONS AND COMPLIANCE

Authorized Representative shall only access Protected Information to the extent necessary to fulfill the stated purposes and shall not use or disclose Protected Information for any other purpose. Authorized Representative shall comply with all applicable privacy, data protection, and confidentiality laws, statutes and regulations in effect during the term of this Form.

Authorized Representative represents and warrants that it has obtained all consents and notices required by law for the access, use, or disclosure of Protected Information and that it will maintain records demonstrating such compliance.

5. CONFIDENTIALITY AND SECURITY

Authorized Representative shall implement and maintain administrative, technical and physical safeguards appropriate to the sensitivity of the Protected Information to prevent unauthorized access, use, alteration or disclosure. Authorized Representative will promptly notify Principal upon becoming aware of any unauthorized access, use, or disclosure of Protected Information.

6. AUDIT RIGHTS AND RECORDS

Principal has the right to request records and documentation from Authorized Representative demonstrating compliance with this Form. Authorized Representative shall retain records of disclosures and access to Protected Information for a period of and shall make such records available to Principal upon reasonable written request.

7. INDEMNIFICATION

Authorized Representative shall indemnify, defend and hold harmless Principal from and against any losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising out of Authorized Representative's negligent or willful breach of this Form, except to the extent such loss arises from Principal's own willful misconduct or gross negligence.

8. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the contact addresses below by hand, certified mail, or recognized overnight courier, and shall be effective upon receipt.

9. AMENDMENT; WAIVER; COUNTERPARTS

This Form may be amended only by a written instrument signed by both parties. No failure or delay by either party in exercising any right under this Form will constitute a waiver of that right. This Form may be executed in counterparts, each of which will be deemed an original and all of which together will constitute one and the same instrument.

10. GOVERNING LAW

This Form shall be governed by and construed in accordance with the laws of the state indicated by Principal below, without regard to conflict of law principles.

11. ENTIRE AGREEMENT

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous understandings, agreements, representations and warranties, whether written or oral, relating to that subject matter.

12. SEVERABILITY

If any provision of this Form is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, the remaining provisions will remain in full force and effect and the parties shall negotiate in good faith a valid substitute provision that most nearly effects the parties' original intent.

ADDITIONAL ACKNOWLEDGMENTS

Principal warrants that the person signing below on Principal's behalf has full legal authority to grant the permissions set forth in this Form. Principal further acknowledges that it may revoke this authority at any time as provided herein.

I certify that I have the legal capacity and authority to grant the privacy access described in this Form.

Sign Now