Legal Release of Information Form

LEGAL RELEASE OF INFORMATION FORM

This Release of Information is made by the undersigned Authorizing Individual: Client Name: Date of Birth: Identification (last 4 digits of SSN or ID): (collectively, the "Authorizing Individual") authorizes the disclosure of protected information by the Provider: Provider Name: to the Recipient: Recipient Name: .

RECITALS

WHEREAS, the Authorizing Individual is the person to whom the protected information pertains and has the legal right to authorize disclosure of such information; and

WHEREAS, the Provider maintains records and information concerning the Authorizing Individual which may be protected under applicable privacy, health, educational, and other confidentiality laws; and

WHEREAS, the Authorizing Individual desires to permit disclosure of certain defined information to the Recipient for the limited purposes described below.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, and for other good and valuable consideration, the parties agree as follows:

1. DEFINITIONS

"Protected Information" means any and all records, documents, communications, or data, whether oral, written, electronic, or otherwise, that relate to the Authorizing Individual and that are protected by law, including but not limited to medical records, mental health records, substance use treatment records, HIV-related information, educational records, and financial or employment records.

2. AUTHORIZATION

The Authorizing Individual hereby authorizes the Provider to disclose the Protected Information specified in Section 3 to the Recipient for the purposes specified in Section 4. This authorization is specific, informed, and voluntary. The Provider may rely upon a photocopy or electronic copy of this signed authorization as if it were the original.

3. INFORMATION TO BE RELEASED

Select the categories of Protected Information to be disclosed (check all that apply):

Medical records (including diagnoses, treatment notes) Mental health and psychotherapy notes Substance use treatment records HIV-related information Billing and payment records Educational records Employment records Legal records or correspondence

4. PURPOSE OF DISCLOSURE

Purpose(s) for which disclosure is authorized (check all that apply):

Continuing medical care or treatment Insurance, claims, or payment matters Legal proceedings or representation Personal use by the Authorizing Individual

5. DURATION; REVOCATION

This authorization is effective immediately upon execution and shall expire on: unless earlier revoked in writing by the Authorizing Individual. Revocation must be signed by the Authorizing Individual and delivered to the Provider at the address below; revocation shall not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

6. REDISCLOSURE

The Recipient is notified that the Protected Information disclosed pursuant to this authorization may be subject to further disclosure by the Recipient and, in that event, may no longer be protected by applicable privacy laws. If Special Categories of Information such as psychotherapy notes, HIV status, or substance use treatment records are disclosed, such disclosure is made only to the extent permitted by law and only where the Authorizing Individual has expressly authorized release of such categories.

7. FEES AND COSTS

The Provider may charge reasonable, itemized fees for the preparation, copying, and delivery of records as permitted by law. Such fees, if any, shall be paid by:

8. CONFIDENTIALITY; COMPLIANCE

The Provider and the Recipient shall safeguard Protected Information and shall comply with all applicable federal, state, and local privacy and confidentiality statutes, regulations, and rules. Each party represents that it will use the Protected Information only for the purposes set forth in this authorization and will maintain appropriate administrative, technical, and physical safeguards to protect the information from unauthorized use or disclosure.

9. INDEMNIFICATION; LIMITATION OF LIABILITY

The Recipient agrees to indemnify and hold harmless the Provider and the Authorizing Individual from any claims, liabilities, losses, or damages arising from the Recipient's wrongful use or disclosure of the Protected Information, except to the extent caused by the Provider's gross negligence or willful misconduct.

10. NOTICES

11. GOVERNING LAW

This Release shall be governed by and construed in accordance with the laws of the state identified below, without regard to conflict of law principles. State of Governing Law:

12. ENTIRE AGREEMENT

This Release constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral, relating to the disclosure of Protected Information.

13. AMENDMENT; WAIVER

This Release may be amended only by a writing signed by both the Authorizing Individual and the Recipient. No waiver of any provision shall be effective unless in writing and signed by the party waiving compliance.

14. SEVERABILITY

If any provision of this Release is held to be invalid, illegal, or unenforceable, such provision shall be modified to the extent necessary to make it valid and enforceable; otherwise such provision shall be severed and the remainder of this Release shall remain in full force and effect.

15. COUNTERPARTS

This Release may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. A facsimile, photocopy, or electronic copy of a signature shall be effective as an original signature.

CERTIFICATION BY AUTHORIZING INDIVIDUAL

By signing below, the Authorizing Individual certifies that they have read and understand this Release, that they are the person identified above (or are authorized to act on behalf of such person), that the release of the Protected Information is voluntary, and that they understand the potential for redisclosure as described herein.

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