Requesting Permission to use Copyrighted Material

Name of Company/Medical Center_____________________

Contact Name_____________________________________

Address__________________________________________

State, Zip ________________________________________ Country____________

Email and website_______________________________  

Phone____________________________________________

I am writing to ask your permission to utilize the Scott Triggers copyrighted tool (attached) for the following: (check all that apply)

_____  reprint   _____  photocopy ______Publication        (No charge)

_____ Digitize and incorporate into electronic medical records (EMR).  (Annual Fee applies for EMR integration up to 5 locations/hospitals in the same company). If more than 5 hospitals please contact Susan Scott at scotttriggers@gmail.com for a quote.

$1,000 annual fee payable to Susan M. Scott includes copyrighted tool integration into EMR such as EPIC, Cerner, MEDITECH, McKESSON, Allscripts, eClinicalWorks, NextGen, Athenahealth Healthland, Medsphere, QuadraMed, Sigmund, or others.

Included in the annual fee is the Scott Triggers® Solution resources and one hour of complimentary consulting time per online media for the purpose of strategic planning, and education. Three-year contracts available for 5% discount.

PERMISSION GRANTED:

I have the authority to grant the permission requested herein and I hereby grant

______________________________________________________________________permission to use the above referenced material in the manner described.

______________________________________

 Susan M. Scott, CEO Scott Triggers PLLC

Copyright Holder's Signature  Date_______________ Expiration Date_______