Legal Records Release Form

LEGAL RECORDS RELEASE FORM

This Legal Records Release Form is made by and between Releasor Name: , Releasor Address: , and Recipient Name: , Recipient Address: . Date of Authorization: .

RECITALS

WHEREAS, Releasor is either the subject of or otherwise authorized to request release of certain records and information concerning Releasor; and

WHEREAS, Recipient has requested access to specified records for a lawful purpose and Releasor desires to permit disclosure of such records to Recipient under the terms and limitations set forth herein; and

WHEREAS, the parties wish to set forth the scope, limitations, and conditions under which records may be released and used.

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

1. AUTHORIZATION TO RELEASE RECORDS

Releasor hereby authorizes any custodian, holder, or provider of records in Releasor's name or pertaining to Releasor to disclose and deliver to Recipient, for the period and subject to the limitations set forth in this form, the records and information described in Section 2. This authorization includes release by electronic transmission, facsimile, or hard copy where available and permitted by applicable law.

2. SCOPE OF RECORDS TO BE RELEASED

The following categories of records are authorized for release (check all applicable categories and specify additional detail where requested):

Medical records, including histories, diagnoses, treatment notes, laboratory reports, and immunizations.

Mental health and behavioral health records, including psychotherapy notes only if expressly authorized below.

Legal records, contracts, pleadings, and court-related documents.

Financial and billing records.

Other:

Psychotherapy notes: if release of psychotherapy notes is requested, the Releasor must initial here to authorize release of psychotherapy notes: .

3. PURPOSE OF DISCLOSURE

4. DURATION AND REVOCATION

This authorization shall become effective on the Date of Authorization set forth above and shall expire on: Expiration Date: , or upon earlier written revocation by Releasor delivered to Recipient at the Notices address specified in Section 10. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of written revocation.

5. REDISCLOSURE AND CONFIDENTIALITY

Recipient understands that the records received pursuant to this authorization may be subject to further protection under applicable federal or state privacy laws. Recipient agrees not to redisclose such records except as permitted by law or with additional written authorization from Releasor. Releasor acknowledges that once the records are disclosed to Recipient, Recipient may lawfully redisclose them pursuant to applicable legal obligations.

6. FEES AND COSTS

Releasor agrees to pay reasonable fees associated with copying, retrieval, and transmission of records. If a fee limit is desired, specify a maximum: . Fees required by the custodian must be paid prior to release unless other arrangements are made in writing.

7. NO CONDITION ON TREATMENT OR BENEFITS

Releasor understands that signing this authorization is voluntary and will not affect Releasor's eligibility for treatment, insurance benefits, employment, or other services, unless conditioning such services on this release is permitted by law and has been explicitly stated in separate written documentation.

8. REPRESENTATIONS, WARRANTIES, AND INDEMNIFICATION

Releasor represents and warrants that Releasor is the subject of the records or has legal authority to authorize disclosure. Releasor agrees to indemnify and hold harmless the Custodian and Recipient from any claims, liabilities, losses, or damages arising from misrepresentation of authority or from improper reliance on this authorization, except to the extent such claims arise from gross negligence or willful misconduct by the Custodian or Recipient.

9. NOTICE PROCEDURES

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles. This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, both written and oral. If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions will remain in full force and effect.

11. AMENDMENT; WAIVER; COUNTERPARTS

This Agreement may be amended only by a written instrument signed by both parties. No waiver of any breach or default shall be deemed a waiver of any subsequent breach. This Agreement may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one instrument.

12. CERTIFICATION

By signing below, Releasor certifies that the information provided is true and correct to the best of Releasor's knowledge; Releasor understands the scope and purpose of this authorization; and Releasor consents to release of the specified records in accordance with this Agreement.

Sign Now