Access Family Health Services

Becoming a Patient

As a patient of Access Family Health Services, 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 northeast Mississippi.

 

Please bring the following documents on your 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 enter the information requested and then click on the "Submit" button.
Patient Information
Sex/Gender
Primary Language
Do you need translation services?
Marital Status
Race
Ethnicity
Agricultural Worker
Housing
Veteran (Have you ever served on active military duty?)
Employment/Student
Income of patients at the Health Center is a Federal reporting requirement. Thank you for providing this information.
Emergency Contact
Responsible Party Information
Sex/Gender
Insurance Information (Medicaid, Medicare, Private Insurance card is required)
Type of Insurance
Do you have an insurance that covers you before Medicare?
Your visit today is covered by
Authorization for Diagnosis and Treatment

I hereby consent to the medical, dental, or mental health examination, treatment, and procedures which may be performed during the office visits, including but not limited to lab work, x-rays, exams, injections, immunization, dental fillings, extractions and anesthesia (local), as may be ordained advisable or necessary by the attending physician, advanced practice registered nurse practitioner, physician assistant, or dentist of Access Family Health Services (AFHSI).

Assignment of Benefits

I hereby give permission to AFHSI 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.

Notice of Privacy Practices

I acknowledge that I have reviewed AFHSI'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 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 AFHSI's privacy practices. This authorization is voluntary and refusal to consent to photographs will not affect the medical care I will receive at AFHSI.

Patient's Bill of Rights and Responsibilities

I acknowledge that I have reviewed and agreed with AFHSI’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.

Financial Agreement

Your care at AFHSI is a partnership between you and the staff of AFHSI. 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 AFHSI 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 Collection Department. I understand that if I fail to pay my bill, AFHSI reserves the right to limit services to me.

For Patient with Insurance:

I understand that AFHSI will bill my insurance company. I agree to show current insurance information at each visit and notify AFHSI 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 AFHSI or their representative to contact me at the numbers given if my account becomes delinquent.

By submitting this form you acknowledge that all of the information entered is true and correct, and that you have read and agree with the above consent and agree to its terms.

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