Register

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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 Smoking Cessation claims.
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I certify that the information above is true and accurate to the best of my knowledge. I hereby authorize my health care provider to release my information identified in this form to SCT Management Services. I authorize the release of my Protected Health Information (PHI) for the purpose of contacting me, coaching me in quitting smoking, giving feedback regarding my quit progress to my healthcare provider(s), and permission for my healthcare provider to forward my information to other health care providers (ex., the quit-line for telephone counseling) directly or indirectly involved in treating me relating specifically to smoking cessation services.
 
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.