Legal Signature ROI

LEGAL SIGNATURE ROI

This Release of Information ("Release") is made and entered into as of Effective Date: by and between Authorizing Party: , Date of Birth: , residing at (hereinafter "Authorizing Party"), and Receiving Party: , located at (hereinafter "Receiving Party").

Recitals

WHEREAS, Authorizing Party possesses confidential records and information concerning the Authorizing Party's identity, health, employment and other protected matters (collectively, "Protected Information");

WHEREAS, Authorizing Party desires to permit disclosure and authorized use of certain Protected Information by disclosing entities and providers to the Receiving Party for the limited purposes set forth below; and

WHEREAS, Receiving Party agrees to receive and use such Protected Information subject to the restrictions, limitations and conditions of this Release and applicable law.

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

1. Definitions

"Protected Information" means any information, whether oral, written or electronic, that identifies the Authorizing Party and that relates to the Authorizing Party's medical history, mental or physical condition, payment history, employment records, or other personally identifiable information that is protected by law.

2. Authorization and Scope

Authorizing Party hereby authorizes all providers, custodians and holders of Protected Information, including but not limited to medical providers, insurers, employers and legal representatives, to disclose and deliver Protected Information to Receiving Party for the following scope and purposes.

Medical records, including diagnosis, treatment and progress notes
Billing and insurance records
Employment and wage records
Legal case files and related correspondence
Other:

3. Purpose of Disclosure

4. Method and Format of Disclosure

Disclosures may be made in written, electronic or verbal form as reasonably required by Receiving Party to accomplish the stated Purpose. The parties acknowledge that electronic transmission may carry inherent risks and that Receiving Party will implement commercially reasonable safeguards.

Paper copies   Electronic copies (secure transfer)   Fax   Other:

5. Duration and Revocation

This Authorization shall become effective on the Effective Date set forth above and shall expire on Expiration Date: unless earlier revoked in writing by the Authorizing Party. Revocation will not affect disclosures already made in reliance upon this Authorization prior to receipt of the revocation by the holder of the records.

6. Redisclosure and Confidentiality

Receiving Party acknowledges that certain Protected Information may be subject to statutory or regulatory protections. Receiving Party agrees not to redisclose Protected Information except as expressly permitted by this Release or as required by law. If Receiving Party is compelled by law to disclose Protected Information, Receiving Party will provide Authorizing Party with reasonable advance notice to permit Authorizing Party to seek protective relief where permitted.

7. Fees and Costs

Providers may charge reasonable fees for copying or preparing records. Unless otherwise agreed in writing, Receiving Party shall be responsible for fees associated with duplication, postage and delivery of Protected Information.

8. Liability and Indemnification

Receiving Party shall use Protected Information only for the Purpose stated herein and shall be liable for any unauthorized use or disclosure. Receiving Party agrees to indemnify and hold harmless Authorizing Party and any disclosing provider from and against any losses, claims or liabilities resulting from Receiving Party's breach of this Release or unauthorized redisclosure.

9. Notices

10. Amendments and Waiver

No amendment, modification or waiver of any provision of this Release will be effective unless in writing and signed by both parties. A waiver of any breach or default shall not constitute a waiver of any subsequent breach or default.

11. Governing Law; Venue

This Release shall be governed by and construed in accordance with the laws of the state identified for governing_law: , without regard to conflict of law principles. Venue for any dispute arising under this Release shall lie exclusively in the state or federal courts located in the county specified by the parties.

12. Entire Agreement; Severability

This Release constitutes the entire agreement between the parties relating to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and communications regarding the same. If any provision of this Release is found to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

13. 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 or electronic copy of a signature shall be deemed an original signature for all purposes.

Acknowledgement

Authorizing Party acknowledges that the Authorizing Party has read and understands the terms of this Release, that the Authorizing Party may refuse to sign this Release, and that signing this Release is voluntary. Authorizing Party further acknowledges receipt of a copy of this Release upon request.

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