I hereby authorize Lott Behavioral Health, Ltd. to furnish my insurance company all information that may be requested concerning claim processing. I am financially responsible for charges not covered by my insurance company. I hereby assign to Lott Behavioral Health, Ltd. all monies to which I am entitled for expenses relative to the services received. I understand that if I am self-pay or have out-of-network insurance that payment is due in full at the time of service and my insurance company will need to reimburse me personally.

The office currently uses an automated system to send some appointment reminders. These reminders, whether through the automated system or otherwise, are given as a courtesy and do not affect the cancellation policy. The system currently offers reminders by email as well as one of the following 2 additional methods: texting or automated call reminders, but these options could change in the future. The current system requires email in order to work.

I consent to receive emails, calls, or text messages from the practice at my phones and any number forwarded or transferred to/from that number or emails to receive communication as stated above. I understand that this request to receive emails, calls, and text messages will apply to all future appointment reminders unless I request a change in writing. The practice does not charge for this service, but standard data rates may apply as provided in my plans. I understand that although the systems use secure communication, no electronic communication can be completely secure from all unforeseen circumstances.