Legal Record Release Form

LEGAL RECORD RELEASE FORM

This Legal Record Release Form is made by and between Releasor Name: (hereinafter "Releasor") and Recipient Name: (hereinafter "Recipient") effective as of .

RECITALS

WHEREAS, Releasor is the lawful owner or authorized representative of certain records and information relating to Releasor identified below; and

WHEREAS, Recipient has requested access to specified records for the legitimate, specified purpose set forth in this Form; and

WHEREAS, Releasor desires to authorize the disclosure of those records to Recipient under the terms and conditions contained herein.

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

1. AUTHORIZATION

Releasor authorizes any person, entity, custodian or holder of records identified in Section 2 to disclose and release to Recipient the records specified in Section 2 for the purposes described in Section 3. This authorization includes the release of information whether maintained in paper, electronic, photographic or other form and includes copies, summaries and reproductions.

2. RECORDS TO BE RELEASED

The records to be released include the following categories (select all that apply) and any specifically described items below:

Medical records Court/case records Financial records

Educational records Law enforcement records Other (describe)

Specific date range for records to be released: From through .

3. PURPOSE AND USE

The records shall be used by Recipient solely for the following purpose(s):

4. DURATION AND EXPIRATION

This authorization is effective on the Effective Date and remains in effect until or until revoked in writing by Releasor as provided in Section 5. If no expiration date is provided, this authorization will expire one year from the Effective Date unless otherwise required by applicable law.

Alternatively, check if this authorization is to remain in effect indefinitely: Permanent authorization (no expiration)

5. REVOCATION

Releasor may revoke this authorization at any time by delivering written notice of revocation to the custodian of records and to Recipient at the addresses set forth in Section 10. Revocation shall be effective upon receipt by the custodian and Recipient, except to the extent that action has already been taken in reliance on this authorization. Date of written revocation (if applicable):

6. REDISCLOSURE AND USE LIMITATIONS

Recipient acknowledges that certain records may be confidential or protected by law. Recipient will use reasonable safeguards to protect the confidentiality of disclosed records and will not redisclose such records except (a) as authorized in writing by Releasor, (b) as required by law, or (c) as necessary to accomplish the Purpose described in Section 3. Any authorized redisclosure that is inconsistent with applicable confidentiality laws remains subject to those laws.

7. FEES

Releasor understands that custodians of records may charge reasonable fees for search, copying and administrative costs. Responsibility for payment of such fees shall be:

Releasor Recipient Third party (identify below)

Estimated or agreed fee amount (if known):

8. REPRESENTATIONS AND WARRANTIES

Releasor represents and warrants that Releasor is the person lawfully authorized to execute this authorization for the records specified herein and that the consent provided herein conforms to all requirements of applicable law. Releasor further represents that the information provided to identify the records and the recipient is complete and accurate to the best of Releasor’s knowledge.

9. INDEMNIFICATION

To the fullest extent permitted by law, Recipient agrees to indemnify, defend and hold harmless Releasor and any custodian who releases records in good faith pursuant to this authorization from and against any claims, liabilities, losses or expenses (including reasonable attorneys' fees) arising from Recipient's unauthorized use or further disclosure of the records beyond the scope expressly permitted by this Form.

10. NOTICES

Notices shall be deemed given when delivered in person, by certified mail, or when delivered by nationally recognized overnight courier to the addresses provided above or to such other address as either party may designate in writing in accordance with this Section.

11. MISCELLANEOUS

Governing Law: This Form shall be governed by and construed in accordance with the laws of the jurisdiction specified by the parties: , without regard to conflict of law principles.

Entire Agreement: This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, whether written or oral, relating to the same.

Severability: If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and shall be construed so as to give effect to the intent of the parties.

Amendments and Waiver: No amendment or waiver of any provision of this Form shall be effective unless it is in writing and signed by both parties. The failure of either party to enforce any right under this Form shall not waive that right.

Counterparts: This Form may be executed in counterparts, each of which shall be deemed an original, and copies transmitted by electronic means shall be deemed originals for all purposes.

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