Medical Records Release Waiver

MEDICAL RECORDS RELEASE WAIVER

This Medical Records Release Waiver ("Waiver") is entered into by and between Patient Name: with Date of Birth: and Recipient Name: . The medical records to be disclosed are held by Provider: . Patient Address:

RECITALS

WHEREAS, Patient is the individual to whom the medical records and protected health information pertain and has the legal authority to authorize disclosure of such records; and

WHEREAS, Recipient requests access to certain medical records maintained by Provider for the specific purposes set forth herein and agrees to receive and protect such records consistent with applicable privacy laws; and

WHEREAS, Patient desires to authorize Provider to disclose the described medical records to Recipient under the terms and conditions of this Waiver.

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

1. AUTHORIZATION

Patient hereby authorizes Provider to disclose to Recipient the medical records and protected health information described below. This authorization includes disclosure by written, electronic, or verbal means when applicable to the format maintained by Provider.

2. SCOPE AND PURPOSE

The scope of this authorization includes all categories of records specifically described above. The records disclosed under this Waiver may be used by Recipient only for the following purposes (check all that apply):

Continuity of care / treatment
Insurance or benefits claim
Legal proceedings
Personal use / personal records
Other:

3. SENSITIVE INFORMATION

Patient hereby expressly authorizes disclosure of the following categories of sensitive information only if the corresponding checkbox is selected. Provider will not disclose categories that are not expressly authorized below.

Mental health / psychotherapy notes
Substance abuse treatment records
HIV / AIDS-related information
Genetic testing results

4. TIME PERIOD

The authorization applies to records created between and . If no dates are specified, the authorization applies to all records in Provider's possession relating to Patient.

5. EXPIRATION

This authorization expires on unless revoked earlier in writing. Alternatively, select the following for no automatic expiration:

No expiration; remains in effect until revoked in writing by Patient.

6. REVOCATION

Patient may revoke this authorization at any time by providing a written notice of revocation to Provider at the address below, except to the extent Provider or Recipient has already relied upon the authorization. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

7. REDISCLOSURE AND USE LIMITATIONS

Recipient understands that information disclosed pursuant to this authorization may be subject to additional federal and state confidentiality laws and regulations. Recipient shall not further disclose the information except as permitted by law or with further written authorization from Patient. Recipient will employ appropriate safeguards to protect the confidentiality of the records.

8. FEES AND COSTS

Provider may charge reasonable fees for copying, postage, and preparation of records in accordance with Provider's policies and applicable law. Recipient acknowledges responsibility for payment of such fees unless otherwise agreed in writing.

9. LIABILITY AND INDEMNIFICATION

Recipient agrees to indemnify and hold harmless Provider and Patient from any claims, liabilities, losses, or damages arising from Recipient's unauthorized use or further disclosure of the records, except to the extent caused by Provider's breach of applicable law or gross negligence.

10. NOTICES

Any notice, request, or communication required or permitted under this Waiver shall be in writing and delivered to the addresses below by hand, certified mail, or other verifiable delivery method.

11. GOVERNING LAW

This Waiver shall be governed by and construed in accordance with the laws of the state specified below without regard to its choice-of-law principles. The Parties submit to the exclusive jurisdiction of the state and federal courts located in that state for resolution of disputes arising under this Waiver.

12. ENTIRE AGREEMENT; SEVERABILITY

This Waiver constitutes the entire agreement between the Parties with respect to its subject matter and supersedes all prior agreements and understandings. If any provision of this Waiver is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

13. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Waiver shall be effective unless in writing and signed by both Parties. Failure or delay in enforcing any provision shall not constitute a waiver. This Waiver may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

14. ACKNOWLEDGMENT AND CERTIFICATION

By signing below, Patient certifies that Patient has read and understands the terms of this Waiver, that the authorization is given voluntarily, and that Patient may receive a copy of this Waiver upon request. Recipient acknowledges its obligations under this Waiver and applicable law to safeguard disclosed information.

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