Third-Party Data Access Authorization Form
1. Data Owner Information
Full Name
Contact Information
2. Third-Party Information
Third-Party Name/Organization
Contact Information
3. Data to Be Accessed
Description of Data
4. Purpose of Access
Purpose/Reason for Data Access
5. Duration of Access
Start Date
End Date
6. Authorization
I authorize the third party named above to access my data as specified in this form.
Data Owner Signature
Date