BRR New Client Info and Tx Consent

I need to have a form recreated with a couple of small changes to the text: 1. Delete the first paragraph on the second page 2. Change the second paragraph to read: I agree that I am financially responsible as indicated in the Financial Responsibility Form and agree to pay all fees and charges related to my treatment unless another party agrees in writing to be financially responsible in my stead. If a party other than myself agrees to be financially responsible for my treatment, my signature below constitutes my consent to release information for the following: a) the fact that I am in treatment with Bright Road Recovery; b) dates and types of service; c) billing and accounting information, including diagnosis for the purposes of providing superbills or other insurance-related purposes; d) billing, accounting and/or superbill information may be exchanged via e-mail with the financially responsible party (unless I indicate I do not wish to have information shared via email). 2a. The "I agree" radio button is a required field--which is to say that it has to be chosen as part of the form in order to continue/sign it/save it. 3. The boxes under the superbill paragraph should be an either/or option, not requiring both boxes to be checked