Client Contact Authorization Form



Client Contact Authorization FormClient Name: FORMTEXT Enter TextCity: FORMTEXT Enter TextState: FORMTEXT Enter TextPhone: FORMTEXT Enter NumberEvolution includes sensitive data, such as pay rates and social security numbers. Because of the sensitive nature of this information, iSystems requires written authorization to be on file prior to disclosing anything to employees of your service bureau.If someone from your service bureau calls for assistance and they are not on the list, we cannot provide any information to them. This may result in a delayed response in resolving your issue.You may not want iSystems to disclose all data to all contacts. If there are limitations to what we cannot discuss with a contact, please indicate it in the Restrictions column. If no restrictions are listed, all information requested will be given to the contact, for example employee rates and salary.The following people are authorized to contact iSystems on behalf of: FORMTEXT Service Bureau Name.NameEmail AddressPhoneRestrictions (if Applicable) FORMTEXT Name FORMTEXT email address FORMTEXT No special characters Ext: FORMTEXT ????? FORMTEXT ????? FORMTEXT Name FORMTEXT email address FORMTEXT No special characters Ext: FORMTEXT ????? FORMTEXT ????? FORMTEXT Name FORMTEXT email address FORMTEXT No special characters Ext: FORMTEXT ????? FORMTEXT ????? FORMTEXT Name FORMTEXT email address FORMTEXT No special characters Ext: FORMTEXT ????? FORMTEXT ?????By signing this form, I authorize iSystems to disclose information to the contacts listed above. 16885971714500Authorized Signature: Name: FORMTEXT Your Name Date: FORMTEXT DATE \@ "M/d/yyyy" 9/7/20168/22/2013Email or fax back to iSystems.Email to: support@Fax to: (802) 655-8340iSystems Use OnlyManager ApprovalDate ................
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