Legal Privacy Release Form

LEGAL PRIVACY RELEASE FORM

This Privacy Release Agreement is entered into on by and between Releasor Name: with address (hereinafter "Releasor"), and Recipient Name: with address (hereinafter "Recipient").

RECITALS

WHEREAS, Releasor possesses certain personal, financial, medical, employment and/or educational information that is private and confidential in nature and desires to permit the disclosure of a defined subset of such information for the purposes set forth below; and

WHEREAS, Recipient is an individual or entity that has requested authorization to receive specified categories of Releasor's private information in reliance upon Releasor's express written permission; and

WHEREAS, the parties desire to set forth their mutual obligations and limitations concerning the disclosure, use, protection, and potential redisclosure of the information described herein.

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

1. AUTHORIZATION TO DISCLOSE

Releasor hereby authorizes Recipient to request, obtain, inspect and copy the following categories of Releasor's information (check applicable categories and specify where required):

Medical and health records Financial and banking records Employment and payroll records

Educational records Government-issued identification Other

2. PURPOSE OF DISCLOSURE

The information authorized by this Agreement may be disclosed by Recipient only for the following purpose(s):

3. SCOPE AND LIMITATIONS

Recipient may use the disclosed information only to the extent necessary to accomplish the Purpose expressly set forth above. Recipient shall not disclose, sell, transfer, publish, or otherwise distribute the information to any third party except as expressly authorized in writing by Releasor or as required by law. Any further disclosure beyond the scope of this Authorization requires a separate written consent signed by Releasor.

4. DURATION AND TERMINATION

This Authorization is effective as of the Effective Date set forth above and shall remain in effect until the earlier of:

(a) a specific termination date of ; or (b) the date on which Releasor provides written revocation under Section 5 below. Notwithstanding termination or revocation, Recipient may retain copies of information as required to comply with applicable recordkeeping or legal obligations, provided such retained copies remain subject to the confidentiality obligations set forth in this Agreement.

5. REVOCATION

Releasor may revoke this Authorization at any time by providing written notice to Recipient at the address for Notices provided below. Revocation will be effective upon receipt by Recipient, except to the extent Recipient has already taken action in reliance on this Authorization or where otherwise prohibited by law.

6. CONFIDENTIALITY, SAFEGUARDS AND REDISCLOSURE

Recipient shall maintain the confidentiality of Releasor's information and implement reasonable administrative, technical, and physical safeguards to protect against unauthorized use or disclosure. Recipient shall limit access to the information to those employees, contractors, or agents who have a need to know in order to accomplish the Purpose and who are bound by confidentiality obligations at least as protective as those contained herein. Recipient shall not permit any further redisclosure of the information except as permitted by this Agreement or as required by law.

7. REPRESENTATIONS AND WARRANTIES

Releasor represents and warrants that Releasor is the data subject of the information disclosed herein or otherwise has the legal authority to execute this Authorization and permit the disclosure. Recipient represents and warrants that it will use the disclosed information solely as authorized herein and in compliance with all applicable laws governing privacy and data protection.

8. INDEMNIFICATION

To the extent permitted by law, Recipient shall indemnify, defend and hold harmless Releasor from and against any and all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising from Recipient's breach of this Agreement, unauthorized disclosure of the information, or negligent handling of the information.

9. NOTICES

All notices, demands or other communications required or permitted under this Agreement shall be in writing and delivered personally, sent by certified mail (return receipt requested), or by nationally recognized overnight courier to the parties at the following addresses (or to such other address as a party may designate by notice):

10. AMENDMENT, WAIVER AND COUNTERPARTS

Any amendment to this Agreement must be in writing and signed by both parties. No waiver of any provision shall be effective unless in writing signed by the party waiving the right. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. GOVERNING LAW

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

12. ENTIRE AGREEMENT

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

13. SEVERABILITY

If any provision of this Agreement is held to be invalid or unenforceable under applicable law, such provision shall be deemed replaced by a valid, enforceable provision that most closely matches the intent of the original provision, and the remainder of this Agreement shall remain in full force and effect.

14. THIRD-PARTY RECIPIENTS

The Releasor authorizes Recipient to disclose the authorized information to the following third parties if necessary to accomplish the Purpose. List third parties and relationship to purpose:

15. MISCELLANEOUS

The headings contained in this Agreement are for convenience only and shall not affect the meaning or interpretation of this Agreement. The parties acknowledge that they have had the opportunity to seek independent legal advice prior to executing this Agreement.

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