PLEASE CONFIRM (by checking box). LIGHTHOUSE PSYCHIATRY BRAIN HEALTH CENTER providers: (1) DO NOT provide any forensic psychiatry/therapy mandated by court order, state professional licensing boards, or any evaluations will be used as material items for future court or board hearings; (2) not all providers accept Medicare; and (3) not contracted with medicaid (AHCCCS).

PLEASE CONFIRM (by checking box). LIGHTHOUSE WELLHEALTH/WELLHEALTH CLINIC (nonprofit) providers: (1) DO NOT provide any forensic services; (2) not all providers accept Medicare; and (3) not contracted with medicaid (AHCCCS) [contracting in progress].

PLEASE CONFIRM (by checking box). I am financially responsible for all fees, including insurance deductibles/copays/co-insurance, insurance non-covered services, drug screening, no show/late cancellation, and any accrued balance from services rendered. Beware: my credit/debit card information will be securely stored on fine. I authorize Lighthouse to charge my card to pay for my outstanding fees.