Information Release

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BENEFICIARY INFORMATION

Beneficiary Name
Legal Representative (if applicable)

AUTHORIZATION TO RELEASE INFORMATION

1. Authorization

I hereby authorize Knospe-Lerncenter GmbH to release, disclose, and exchange my health and personal information, as described below, to and with the entity or individual named in this document.

2. Information to be Released

Information to be Released

3. Purpose

Purpose

4. Authorized Recipients

Address

5. Right to Revoke

I understand that I have the right to revoke this authorization at any time by providing written notice to Knospe-Lerncenter GmbH. Revocation will not affect any actions taken before the receipt of the revocation.

6. Statement of Consequences

I understand that once Knospe-Lerncenter GmbH discloses my health information to the recipient, it may no longer be protected by U.S. federal and state privacy regulations and could be re-disclosed by the recipient. However, the information will still be protected under GDPR and any other applicable privacy laws.

7. Authorization Validity

This authorization will remain in effect until discharge from Knospe-Lerncenter GmbH, unless I request an earlier expiration date here:

Optional Expiration Date

Thereafter, this authorization becomes null and void. I understand that I have a right to receive a copy of this authorization.

8. Contact Information for Questions

If you have questions about this authorization or need to revoke it, please contact:

Knospe-Lerncenter GmbH
Georgstr 2, 31675 Bückeburg, Deutschland
Phone: +49 5722 9098399
Email: [email protected]

9. Acknowledgment

I have read and understood this authorization form. I understand that I have a right to receive a copy of this authorization.

By signing below, I agree to the terms and conditions outlined above.

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