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I Am A:
I am a Patient or Consumer
I am a Client or Prospective
Submit a Compliment or Complaint
Please contact us by completing the form below or calling our Consumer Relations Help Desk at
This communication is from a debt collector. This is an attempt to collect a debt. Any information obtained will be used for that purpose.
If you are a consumer trying to obtain information on your account, please complete the form below or call our Consumer Relations Help Desk at
I am authorizing State Collection Service, Inc. (“SCSI”) 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 SCSI.
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.
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.
I am not providing SCSI 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 roommates) and I have taken all precautions to eliminate others from accessing my Electronic Communications.
I am authorizing SCSI to transmit Electronic Communications to the e-mail address I provide to SCSI 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: State Collection Service, Inc. or SCSI In the “Subject” line of the email: An account number or other identifying information
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 SCSI at 1-800-477-7474 (ext. 892) The right to withdraw consent to receive Electronic Communications. I may withdraw my consent by contacting SCSI at 1-800-477-7474 (ext. 892) or by “unsubscribing” in an email sent to me This consent is a continuing consent to SCSI to send me Electronic Communications
I may update my electronic address by contacting SCSI at 1-800-477-7474 (ext. 892) 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 electronically save and display on computer screens Electronic Communications. I may receive a notification from SCSI 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 1.1 April 01, 2012
I am consenting to receipt of Electronic Communications and the terms contained in this form.
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