Becoming a Patient As a patient of Amite County Medical Services, Inc., we invite you to become a partner in your health care. We want to help you stay healthy and manage diseases, and we need your help as we strive to build healthy communities in Southwest Mississippi. How to Get Started You can request an on-line appointment by using our secure on-line appointment form and one of our friendly appointment schedulers will contact you within 48 hours. You may also schedule an appointment by contacting us at (601) 657-8091. Please be prepared to provide your name, date of birth, address, phone number and insurance information. Save time by completing these forms in advance using our downloadable patient registration forms below. You can download, complete, print these forms at home and bring them with you to your first visit. Please see Patient Assistance Programs for more information regarding our payment and billing policies. If you have any questions, please call us at (601) 657-8091. Call the clinic of your choice to make an appointment or fill out an appointment request here. Check locations for telephone numbers and specific hours at each health center clinic. New patients should arrive 30 minutes before appointments so you can see your provider in a timely manner. We request that you fill out the Patient Registration Form in advance to facilitate your registration as a new patient or print the form, fill out the form and bring it to your visit. Please bring the following documents on your visit: Photo ID Insurance card(s), including Medicaid and Medicare at every visit Immunization records for children All current medications Proof of income and address Co-payment or sliding fee costs (Minimum of $35 medical / $45 dental on first visit) We value your time and the time of our staff. If you fail to keep your appointment, a slot is lost that could have been used by someone who is sick. This affects our clinic efficiency and increases the cost of our services. To assist, you will receive an automated appointment reminder approximately 48 hours prior to your scheduled appointment. Please notify the clinic at least 24 hours prior to appointment if you are unable to come. Failure to keep your appointment may result in a delay of rescheduling. If you are late for your appointment, you may be asked to reschedule. Patient Forms Advanced Directive Registration-Patient Medical History Please enter the information requested and then click on the "Submit" button. The fields marked with * are required. Patient Information *First Name MI *Last Name Patient ID # *Street Address *City State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside USA *Zip Code *County *Home Phone Cell/Other *Social Security Number Email Address *Sex/Gender Male Female *Date Of Birth *Primary Language English Spanish Other *Do you need translation services? Yes No *Marital Status Married Single Divorced Widowed Separated Partner *Race Black/African American Asian/Pacific Islander Native American/Alaskan White/Caucasian Native Hawaiian Other Pacific Islander Unknown More than 1 race *Ethnicity Not Hispanic/Latino Hispanic/Latino Unknown/Unreported *Agricultural Worker Seasonal Migrant Not Applicable *Housing Permanent Residence (rent or own) Temporary housing arrangement (living with family or friend) Shelter or Street *Veteran (Have you ever served on active military duty?) Yes No *Employment/Student Full Time Student Part Time Student Full Time Employed Part Time Employed Unemployed Self-Employed Military Active Duty Retired Employment Work Phone Cell Phone Employer Name Employer Address Employer City Employer State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside USA Employer Zip Code *Total Annual Income *Number of People in Your Household Emergency Contact *Name *Phone *Relationship Responsible Party Information *First Name MI *Last Name *Relationship to Patient *Mailing Address *City *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside USA *Zip Code *Phone *Social Security Number *Date Of Birth *Sex/Gender Male Female Insurance Information (Medicaid, Medicare, Private Insurance. Copy of Insurance Cards are Required.) *Type of Insurance No Insurance Medicaid Private Insurance (Complete Information Below) Medicare Do you have an insurance that covers you before Medicare? Yes No Insured Name Insured Date of Birth Medicare Supplement Name Medicare ID Medicaid ID *Primary Insurance *Primary Insurance CoPay *Primary Insurance Group/Policy # *Primary Insurance ID # *Insured Name *Insured Date of Birth Secondary Insurance *Secondary Insurance CoPay *Secondary Insurance Group/Policy # *Secondary Insurance ID # *Insured Name *Insured Date of Birth *Your visit today is covered by Worker's Compensation Not Applicable "Authorization for Diagnosis and Treatment" Permission is hearby granted for any medical or dental treatment, including but not limited to, x-rays, laboratory procedures, examinations, injections, dental procedures, including local or general anesthesia, as may be determined advisable or necessary by the attending physicians or dentists of the Amite County Medical Services, Inc. or its consulting physicians. All X-Rays will be disposed of after the end of the 7th year. The Clinic is authorized to furnish from the patient records requested information or excerpts to any medical service center, third party payers (for billing purposes) and requisite legal, health, or social service facility. I understand that in the event that I fail to pay any balances associated with my account, I will be required to pay collection fees, attorney fees, or any other costs related to collecting this account. I hereby certify that I have read and understand the above authorization. I agree Assignment of Benefits I hereby give permission to ACMS to release any medical information to Medicare, Medicaid, or the insurance company that is needed to receive payment for medical, dental or optical services rendered to me or other persons listed on the patient registration form. I agree Notice of Privacy Practices I acknowledge that I have reviewed ACMS's Notice of Privacy Practices, which describes how medical information about me may be used and disclosed and how I can get access to this information. I may print the privacy practices or obtain a copy of the Notice of Privacy Practices upon request. I agree I hereby consent to have a photograph made of me or my child (or person for whom I am legal guardian) to be used in the medical record, for purposes of identification when a legal document with photo identification is not available, or for medical reasons. I understand that this information will be used in medical records only and will be treated consistently with ACMS's privacy practices. This authorization is voluntary and refusal to consent to photographs will not affect the medical care I will receive at ACMS. I agree Treatment of a Minor I do hereby certify that I have the legal capacity to authorize medical and/or dental treatment for the above named individual as described above. I agree Patient's Bill of Rights and Responsibilities I acknowledge that I have reviewed and agreed with ACMS's Patient's Bill of Rights and Responsibilities. I may print the document or obtain a copy of Patient's Bill of Rights and Responsibilities upon request. I agree Financial Agreement Your care at ACMS is a partnership between you and the staff of ACMS. We rely on the fees paid by you and your insurance company to keep the clinics operating. We are not responsible for any charges by hospitals, other physicians, or any other services outside ACMS without prior written consent. For Patient With No Insurance: I agree to apply for Sliding Fee Discount as recommended by staff. I understand that failure to provide proof of income and complete the process will result in my being responsible for 100% of charges. I agree that I will pay all charges for which I am responsible at the time of service or make payment arrangements with the Finance Department. I understand that if I fail to pay my bill, ACMS reserves the right to limit services to me. I agree For Patient With Insurance: I understand that ACMS will bill my insurance company. I agree to show current insurance information at each visit and notify ACMS with any changes in coverage. I agree to pay my co-payment and required deductible at the time of service and to pay for services not covered by my insurance plan. I will contact my insurance, if necessary, to ensure payment for services that I have received. I authorize ACMS or their representative to contact me at the numbers given if my account becomes delinquent. 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