[SAMPLE] Consent to Release Confidential Information Cell Phone

The following sample authorization form may be effective for allowing one person to authorize another for a third party to release information about telephone, social media, email and/or text messages.

Consent to Release Confidential Information Cell Phone

PERSON AUTHORIZING RELEASE

I _____________________ [Print Name] hereby authorize and request,

Name: _________________________

Note: [Print name of person or entity from whom records are sought, bes practice is to also print the pertinent address, telephone number and other contact information, as well]

INFORMATION AUTHORIZED TO BE RELEASED

to release the following confidential information:

____________________________________________ [describe information that is authorized to be disclosed]

Note:

* If it is a Telephone Number, type the telephone number

* If it is an Email address, type the email address

Pertaining to, or belonging to:

Name: _______________________________________________ [print/type name of person who owns account, which, generally, must be the same as the person authorizing the release]

Address: _______________________________________________ [print/type address of person who owns account, which, generally, must be the same as the person authorizing the release]

Contact Telephone, Email and Fax: [print/type other such contact information of person who owns account, which, generally, must be the same as the person authorizing the release]

For the following period of time:

From ________________________________ [start date] to ___________________________ [end date], inclusive.

LIMITATION ON USE

This information shall be limited for use as follows, only:

_______________________________________________________________ [Print/Type the limited use]

Note: Litigation in Case name and case numeber may be sufficient.

TERMINATION OR MODIFICATION MUST BE IN WRITING

I the undersigned, acknowledge, understand and agree that I may be able to terminate or modify this authorization, but, any such termination or modification must be in writing.

OTHER TERMS

Unless there is a bona fide dispute over the authenticity of the agreement, including my signature, I the undersigned, acknowledge, understand and agree that a photocopy or other electronic form of this Agreement shall be as effective and valid as the original.

I the undersigned, acknowledge, understand and agree that as long as the person releasing the information and the recipients of the information comply with this agreement and follow the legal requirements and standard business practices to protect confidential information, I release those persons from legal liability resulting from the disclosure of the information that I herein authorize to be released.

I, [NAME], HAVE READ THIS AUTHORIZATION TO RELEASE INFORMATION, I UNDERSTAND IT AND AGREE TO THE TERMS

Signature ____________________________________ Date _______________

Want to print your doc?
This is not the way.

Try clicking the ⋯ next to your doc name or using a keyboard shortcut (

CtrlP

) instead.