From time to time, GEISINGER, any of GEISINGER’s employees, agents, successors and assigns, including PAYZEN INC acting as GEISINGER’s agent (we, us or Company) may be required by law to provide to you certain written notices or disclosures in writing (on paper). We may also need your signature in connection with our transactions with you. If you would like, you can agree to receive these documents and provide your signature electronically instead. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the PayZen system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to this Electronic Record and Signature Disclosure (ERSD), please confirm your agreement by clicking ‘APPROVE’ within the PAYZEN system.
At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you through the PayZen system during and immediately after the signing session and, if you elect to create a PayZen account, you may access the documents for a limited period of time (usually 30 days) after such documents are first sent to you. You may request delivery of such paper copies from us by following the procedure described below.
If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below.
If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. Further, you will no longer be able to use the PayZen system to receive required notices and consents electronically from us or to sign electronically documents from us.
Your consent applies to all notices, disclosures, authorizations, acknowledgements, and other documents we provide or make available to you (“Documents”) in connection with product or service we offer, provide to you, or that you apply for, own, use, administer or access, either now or in the future.
To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Even if you provide your consent, we may still in our discretion provide you with any Documents in paper copy. We may require any information you provide to us, or any document you sign, to be delivered to us in writing. You should print or download a copy of any Documents for your own records, including this ERSD.
You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows:
Attn: PAYZEN INC
600 California Street, Suite 14-001
San Francisco, CA 94108
To let us know of a change in your email address where we should send notices and disclosures electronically to you, you can contact us by mail or if you created a PayZen account, you may update it with your new email address through your account preferences.
To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you can contact us by mail and in such letter you must state your email address, full name, mailing address, and telephone number.
To inform us that you no longer wish to receive future notices and disclosures in electronic format you may:
In order to view and retain your electronic Documents, you will need:
You must have a computer or handheld device using a Current Version of an operating system capable of supporting all of the requirements described above. By “Current Version”, we mean a version of the software currently supported by its publisher. We reserve the right to discontinue support of a Current Version of software if, in our sole opinion, it suffers from a security flaw or other flaw that makes it unsuitable for our use of electronic Documents.
If we change these hardware or software requirements, and that change creates a material risk that you would not be able to access or retain your electronic Documents, we will notify you of the revised hardware or software requirements.
Acknowledging your access and consent to receive and sign documents electronically
To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please confirm that you have read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for your future reference and access; or (ii) that you are able to email this ERSD to an email address where you will be able to print on paper or save it for your future reference and access.
By clicking APPROVE within the PAYZEN system, you are consenting to the use of electronic records and signatures in connection with your relationship with us, and also confirming that:
This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.
Print Name of Patient: ***SSN: ***
I authorize PAYZEN INC to use or disclose the following health information:
Demographic information, billing and payment information, summarized information about my provider, services provided and dates of service
The above party may disclose this health information to the following recipients:
Credit bureaus and further credit data vendors
Decision and analytics software platforms for customization of payment plans
Vendors involved in servicing of payment plans
At the request of the Patient or Authorized Representative for payment plan enrollment, payment plan customization and ongoing servicing of the payment plan.
When my outstanding balance is paid in full
I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.
I understand that uses and disclosures already made based upon my original permission cannot be taken back.
I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.
I understand that treatment by any party may not be conditioned upon my signing of this authorization and that I have payment options other than through this payment plan.
I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
I authorize PAYZEN INC ("PayZen") to obtain a credit report from one or more consumer credit reporting agencies. They may use the credit report for any purpose that would be authorized by applicable law in connection with a Payment Plan ("Plan") transaction involving me and including but not limited (i) to make decisions on term and monthly payment of my plan; (ii) to determine how much debt I currently have, in order to determine my debt-to-income ratio; (iv) to obtain my credit score and assign me a PayZen Rating based in part on that score; PayZen may obtain my credit report each time I create a Plan and in connection with Plan servicing or collection.
Financial companies choose how they share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do.
The types of personal information we collect and share depend on the product or service you have with us. This information can include:
When you are no longer our customer, we continue to share your information as described in this notice.
All financial companies need to share personal information to run their everyday business. In the section below, we list the reasons financial companies can share their personal information; the reasons PAYZEN chooses to share; and whether you can limit this sharing.
|Reasons we can share your personal information||Does PAYZEN share?||Can you limit this sharing?|
|For our everyday business purposes — such as to process your transactions, maintain your account(s), respond to court orders and legal investigations, or report to credit bureaus||YES||NO|
|For our marketing purposes — to offer our products and services to you||YES||NO|
|For joint marketing with other financial companies||NO|
|For our affiliates’ everyday business purposes — information about your transactions and experiences||NO|
|For our affiliates’ everyday business purposes — information about your creditworthiness||NO|
|For nonaffiliates to market to you||NO|
email@example.com or go to www.payzen.com
Who is providing this notice? PAYZEN
How does PAYZEN protect my personal information?
To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured files and buildings.
How does PAYZEN collect my personal information?
We collect your personal information, for example, when you
Why can’t I limit all sharing?
Federal law gives you the right to limit only
State laws and individual companies may give you additional rights to limit sharing.
Affiliates – Companies related by common ownership or control. They can be financial and nonfinancial companies.
Nonaffiliates – Companies not related by common ownership or control. They can be financial and nonfinancial companies.
Joint marketing – A formal agreement between nonaffiliated financial companies that together market financial products or services to you.
You consent to receive text messages, calls and voice messages (including prerecorded and artificial voice and autodialed) from us (GEISINGER and PAYZEN INC.), our agents, representatives, affiliates or anyone calling on our behalf at the specific number(s) you have provided to us, or numbers we can reasonably associate with your account (through skip trace, caller ID capture or other means), with information or questions about your account and/or payment plan.
Prior to entering into a Payment Plan Agreement you can cancel the SMS service at any time by texting “STOP” to the short code. After you send the SMS message "STOP" to us, we will send you an SMS message to confirm that you have been unsubscribed. After this, you will no longer receive SMS messages from us.
If you are experiencing issues with the messaging program you can reply with the keyword HELP for more assistance, or you can get help directly at firstname.lastname@example.org or 888-849-7647.
Message and data rates may apply for any messages sent to you from us and to us from you. You will receive no more than 3 messages per week.
If you have any questions about your text plan or data plan, it is best to contact your wireless provider.