1. I am authorizing Radiologybill ("RB") to send me any and all communications electronically ("Electronic Communications"). Electronic Communications includes e-mail, current and future notices and/or disclosures that may be required by law, correspondence, statements and other communications regarding any account placed (now or in the future) with RB.
2. I am acknowledging receipt of this Electronic Communication Consent form, my intent to be bound by the terms of this form and that I am signing this form electronically.
3. I am acknowledging that Electronic Communications: (a) can be intercepted, altered, forwarded or used without authorization or detection, (b) can be circulated, forwarded and stored in paper and electronic files, and (c) may be lost due to technical failure during composition, transmission or storage.
4. I am not providing RB with an e-mail address provided to me by my employer or related in any manner to my workplace or place of employment. I am acknowledging that I do not have a reasonable expectation of privacy in an e-mail address associated in any way with my employment. I am also acknowledging that I am aware of who else in my household may intercept Electronic Communications (for example, family members and roomates) and I have taken all precautions to eliminate others from accessing my Electronic Communications.
5. I am authorizing FSR to transmit Electronic Communications to the e-mail address I provide to RB and to include the following in the Electronic Communications:• In the "To" line of the email: your name or other individual identifying information• In the "From" line of the email: Radiologybill or RB• In the "Subject" line of the email: An account number or other identifying information
6. I am acknowledging I have been informed of the following:• The right to receive a paper version of an Electronic Communication. I may obtain a paper version by contacting RB at 1-888-977-9729 (ext 404).• The right to withdraw consent to receive Electronic Communications. I may withdraw my consent by contacting FSR at 1-888-977-9729 (ext 404) or by "unsubscribing" in an email sent to me. • This consent is a continuing consent to RB to send me Electronic Communications.• I may update my electronic address by contacting RB at 1-888-977-9729 (ext 404)• I must ensure that I can receive Electronic Communications and retain it. I have a computer system with an internet web browser capable of 128-bit encryption and Adobe Acrobat Reader. I have a printer capable of printing any Electronic Communication emailed to me and/or have the ability to electornically save and display on computer screens Electronic Communications.• I may receive a notification from RB that I have a secure email message; that I will be required to create an account to access an Electronic Communication; and, if I fail to create an account, I may not receive a response.
Agreement Version 1.0 - February 26, 2015