Lee's MSketeers Foundation
What is MS?
How to Qualify for Assistance
Lee’s MSketeers Foundation
Consent to Services and Releases of Information
have agreed to be a client of Lee’s MSketeers Foundation and to receive financial assistance and
I give permission to Lee’s MSketeers Foundation, its appointee and its representatives to communicate with my physicians and service providers for the purposes of providing financial assistance and services.
To provide or authorize these services I understand it may be necessary to review and receive copies of my medical records and reports. A copy of this document will be valid as the original.
I understand that by signing this consent form, I am giving my permission for Lee’s MSketeers Foundation to release and exchange information concerning me and my family with those professionals who have provided or may provide services to me and my family with the exception
Electronic Signature Agreement: By typing your name on this form, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.
© 2015 Lee’s MSketeers Foundation. All Rights Reserved.
Registered NJ Nonprofit Corporation ID #0400428252