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In order to utilize this electronic Application for Benefits available to the Scott Class Members, SCTMS will require either your Federal Social Security Number OR Louisiana Driver's License Number. This information will only be used to verify your identity prior to submission of your Application to the Court for final determination of your Class.

By seeking to be approved to participate in the smoking cessation program as a Scott class beneficiary who meets the eligibility requirements of such program, you hereby expressly acknowledge, agree and irrevocably consent that the Smoking Cessation Trust, and its authorized agents and representatives, may verify the information provided to us by you, including but not limited to your Louisiana residency status, social security number, driver's license, medical history, and smoking history. Membership.

If you are unable to provide either your SSN# or DL# please call SCT-Management Services at (504) 529-5665 to speak to an enrollment specialist about an alternative method to register.

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Your Primary Insurance information is not required, however, it can assist SCTMS in correctly processing your application.

How did you hear about us? *
Were you referred by any of our partners listed?
Smoked a cigarette before Sept 1st, 1988? *
Yes
No
Current Resident of LA? *
Yes
No
Attestation: *

I certify that the information above is true and accurate to the best of my knowledge. I hereby authorize my health care provider(s) to release my Protected Health Information (PHI), including but not limited to my information identified in this form, to SCT Management Services or to any other person or entity authorized by HIPAA to receive such information for any purpose permitted under HIPAA, with no further action, consent or authorization required from me. Without limiting the generality of the foregoing, I authorize the release of my Protected Health Information (PHI) for the purpose of contacting me, discussing my eligibility for available smoking cessation services, coaching me in quitting smoking, giving feedback regarding my quit progress to my healthcare provider(s) and to SCT Management Services, and permission for my healthcare provider, SCT Management Services, or any person or entity authorized to release such information under HIPAA, to forward my information to other health care providers or to any other person or entity authorized under HIPAA to receive such information (such as, by way of example only., the quit-line for telephone counseling) directly or indirectly involved in my participation in the smoking cessation or in treating me relating specifically to smoking cessation services.

Electronic Signature: *
Under penalty of perjury, I affirmatively state that:
  1. The information submitted above is true and correct;
  2. I agree to be bound by all policies, and procedures which pertain to benefits available to the Scott II Class and further orders of the Court pertaining to the Scott II Class; and
  3. By entering my name in the space provided for Electronic Signature, above, I understand that I am signing this Application, with the same effect as if I was physically signing a hard-copy Application.
Password Creation: *

Please enter a Password to enable you to access your profile when your application is approved.



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