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PRIOR EXPRESS CONSENT AGREEMENT FORM
I understand that it is important for Healthcare Revenue Recovery Group, LLC., (hereinafter HRRG) to be able to communicate with me and have current information about me, my address, my phone number(s), and any other information about me that may assist HRRG or its agents, successors, assigns, or representatives in locating me or communicating with me. I expressly consent and agree to the terms and conditions contained in this Prior Express Consent Agreement Form.
The provision of my email address is my consent to receive future communications from Healthcare Revenue Recovery Group, LLC (HRRG) by email. Although HRRG will not intentionally transmit private or sensitive information (PHI) to any third party, email is outside of HRRG’s control once transmitted through an unsecured network.
I understand and agree to the following risks:
1. Private or sensitive information (PHI) may be seen by a 3rd party.
2. Future communications sent by HRRG via email may contain PHI.
3. Other unforeseen risks that are not within HRRG’s control.
Authorized Entities: The term Authorized Entities shall mean the above referenced HRRG and its successors, assigns, agents, attorneys, insurers, representatives, employees, officers, shareholders, partners, parents, subsidiaries, affiliated entities, and all agents and representatives of the previously listed persons/entities, including any collection agency or debt collector hired by any of the preceding persons or entities, and all corporations, persons, or entities in privity with any of them.
Communication Consent: I understand that the purpose of this agreement is to authorize the delivery of calls to me using an automatic telephone dialing system or an artificial or prerecorded voice. I also understand that my agreement to the terms of this Prior Express Consent Form is not a condition of the Authorized Entity’s willingness to provide services to me. To the extent permitted by applicable law, and without limiting any other rights Authorized Entity may have, I expressly consent and authorize Authorized Entity to communicate with me for any reason related to one or more unpaid debts, alleged to be owed by me, including collection of amounts owed, using an automated telephone dialing system, other computer assisted technology including, an artificial or prerecorded voice, at the telephone number or numbers I provide below. This consent also applies to any telephone number assigned to a paging service, cellular telephone service, specialized mobile radio service, or other radio common carrier service, or any service for which I am charged for the call. In addition, I further expressly consent and authorize the Authorized Entity to communicate with me at any phone number or email address or other unique electronic identifier or mode that I provided to any Authorized Entity at any time, or using any phone number or email address or other unique electronic identifier or mode that any Authorized Entity finds or obtains on its own which is not provided by me.Any Authorized Entity may communicate with me using any current or future means of communication, including, but not limited to, automated telephone dialing systems, artificial or pre-recorded voices, SMS, text messages, other forms of electronic messages, electronic mail directed to my internet domain address, electronic mail directed at a mobile telephone service, cellular telephone services, internet or world wide web addresses including social and business networking internet sites, or electronic messages or mail otherwise directed to me through any medium. I authorize any and all of the communication methods described in this paragraph even if I will incur a fee or a cost to receive such communications. I further agree to immediately notify the Authorized Entities if any telephone number or email address or other unique electronic identifier or mode that I provided to any Authorized Entity changes or is no longer used by me. I agree that the consent and authorizations I have provided herein may be revoked only in writing addressed to HRRG. Finally, I understand that that the Authorized Entities have relied upon my statements contained herein and on my promise to fulfill my obligations contained herein. I hereby consent and authorize that a photocopy of this authorization may be considered as valid as the original.
This Consent shall enure to the benefit of and be finding upon my heirs, executors, administrators, successors, and assigns. I intend for all Authorized Entities to be third party beneficiaries of the consent I have provided herein.