Legal Release of Information Authorization Form

LEGAL RELEASE OF INFORMATION AUTHORIZATION FORM

This Authorization for Release of Information is made on this day of , , by Authorizing Party: (hereinafter "Authorizing Party"), Date of Birth: , Address: , and Recipient: , Address: .

RECITALS

WHEREAS, Authorizing Party possesses records and information (including but not limited to medical, financial, educational, employment, or legal records) that relate to the Authorizing Party's affairs; and

WHEREAS, Authorizing Party desires to permit disclosure of such records and information to Recipient for the limited purposes set forth in this Authorization; and

WHEREAS, Recipient requires written authorization to obtain and use the information described below.

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

1. AUTHORIZATION AND SCOPE

Authorizing Party hereby authorizes any custodian or holder of records (including but not limited to hospitals, clinics, physicians, insurers, employers, educational institutions, financial institutions, and legal counsel) to disclose and release to Recipient the following categories of information:

Medical records and treatment information
Mental health, behavioral health, and substance use treatment records (if checked, this authorization specifically includes such records to the extent permitted by law)
Financial and billing records
Employment and personnel records
Educational records
Legal and case-related records
Other:

The disclosure authorized hereby includes copies of records, summaries, and communications necessary to accomplish the stated purpose. The disclosure does not authorize the release of genetic test results unless specifically checked in the Other field and described.

2. PURPOSE

The records and information may be used and disclosed by Recipient for the following purpose(s):

3. DURATION; EFFECTIVE DATE; EXPIRATION

This Authorization is effective as of: and shall expire on: , or upon completion of the purpose stated above, whichever occurs first.

Authorizing Party may revoke this Authorization at any time by providing written notice to Recipient and to any holder of records identified herein, except to the extent that action has already been taken in reliance on this Authorization.

4. REDISCLOSURE AND CONFIDENTIALITY

Recipient acknowledges that certain categories of information released pursuant to this Authorization may be protected by statute or regulation. Recipient agrees not to further disclose any information received except as permitted by law or with additional written authorization from Authorizing Party. Recipient shall take reasonable measures to protect the confidentiality of the information and shall notify Authorizing Party in the event of an unauthorized disclosure.

5. METHOD OF RELEASE; FEES

Records may be released by paper copy, secure electronic transmission, facsimile, or verbal communication as appropriate. Preferred method of transmission:

Authorizing Party understands and agrees that the holder of records may charge a reasonable fee for copying and transmission in accordance with applicable law. Recipient shall be responsible for any fees incurred with respect to copying or transmission requested by Recipient.

6. REVOCATION

Revocation must be submitted in writing to Recipient and to any custodian of records identified in this Authorization. Revocation will be effective upon receipt, except to the extent that reliance on this Authorization has already occurred. Revocation shall not affect disclosures made prior to receipt of revocation.

7. LIABILITY; INDEMNIFICATION

Authorizing Party releases and holds harmless any custodian of records and Recipient from liability that may arise from compliance with this Authorization to the extent permitted by law. Recipient agrees to indemnify and defend Authorizing Party for claims arising from Recipient's negligent or willful misuse of disclosed information.

8. NOTICES

9. AMENDMENTS; WAIVER; COUNTERPARTS

This Authorization may be amended or supplemented only by a written instrument signed by Authorizing Party and Recipient. No waiver of any provision of this Authorization shall be effective unless in writing and signed by the party against whom enforcement is sought. This Authorization may be executed in counterparts, each of which is an original and all of which together constitute one agreement.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Authorization shall be governed by and construed in accordance with the laws of the state of: without regard to its conflicts of laws principles. This Authorization constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior oral or written agreements. If any provision of this Authorization is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

ADDITIONAL INFORMATION

Certification: By signing below, Authorizing Party certifies that the information provided herein is true and correct to the best of Authorizing Party's knowledge; that Authorizing Party is the individual whose information is the subject of this Authorization or is duly authorized to act on behalf of such individual; that Authorizing Party understands the nature and purpose of this release; and that Authorizing Party understands that information released pursuant to this Authorization may be subject to redisclosure by Recipient and may no longer be protected under certain privacy laws.

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