Email and Fax Authorization

Email and Fax Authorization

By completing your information below, you agree to these Terms and Conditions without limitation or qualification. These Terms and Conditions will be sent by email to you for your records.

TERMS AND CONDITIONS

I authorize Guardian Capital Management Hawaii LLC and Physicians Financial Recovery Services LLC to use regular email or fax to communicate with me instead of regular mail or certified mail (complete the appropriate information below).

I acknowledge that email and fax communications are not secure, and that confidential information sent via email or fax may be intercepted and used by unauthorized persons.  I accept these conditions and waive any violation of the Fair Debt Collection Practices Act (15 U.S.C. 1692 et. seq.), the Gramm-Leach-Bliley Act (15 U.S.C. §§6801 et. seq.), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA)( 42 U.S.C. §§ 300gg et. seq.) that might arise from an unauthorized interception and/or use of email or fax.

Form must be completed by the individual, business owner or authorized officer. Not by a 3rd party representative. This authorization remains effective until revoked in writing by either party.  To revoke this authorization, enter  “cancel previous authorizations” with your name in the NAME box.  Complete your business information, sign, and submit the form.  You may also return the form to Guardian Capital Management Hawaii LLC or Physicians Financial Recovery Services LLC, 1580 Makaloa St., Suite 920, Honolulu, HI  96814.

A copy of this authorization will be sent to your email address and our internal file.  Please keep a copy of this completed form or the email confirmation for your files.  If you have any questions, please contact us at (808) 948-9309.