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成为病人

As a patient of Amite 县 Medical 服务, 公司., we invite you to become a partner in your 健康 care. We want to help you stay 健康y and manage diseases, 我们需要你们的帮助，努力在密西西比西南部建立健康的社区.

如何开始

您可以使用我们安全的在线预约表格申请在线预约，我们友好的预约调度人员将在48小时内与您联系. 您也可以通过十大网赌信誉网站在阿米特县医疗服务公司安排预约. (601) 657-8091, Liberty Dental 服务 (601) 657-1236, or Pike 县 Medical 服务 (601) 249-3541. Please be prepared to provide your name, 出生日期, address, 电话号码, and insurance information.

Save time by completing forms in advance using our website. (点击这里)你可以在家里填写这些表格，并在你第一次访问之前提交. 有关我们的付款和计费政策的更多信息，请参阅患者援助计划. 如果您有任何问题，请致电我们的阿米特县医疗服务公司. (601) 657-8091, Liberty Dental 服务 (601) 657-1236, or Pike 县 Medical 服务 (601) 249-3541.

  • 致电您选择的诊所预约或填写预约请求在这里.
  • 检查每个保健中心诊所的电话号码和具体时间.
  • 全国十大赌博官网应该在预约前30分钟到达，这样你才能及时见到你的医生.
  • 我们要求您提前填写患者登记表，以便您作为新患者登记或打印表格, fill out the form and bring it to your visit.

Please bring the following documents on your visit:

  • 照片的身份证
  • Insurance card(s), including 医疗补助计划 and 医疗保险 at every visit
  • Immunization records for children
  • 目前服用的所有药物(处方药和非处方药)
  • Proof of income and address
  • 共同支付或滑动费用(首次就诊医疗费用最低为35美元/牙科费用最低为45美元)

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. 这影响了我们诊所的效率，增加了我们的服务成本. 协助, 您将在预定预约前约48小时收到自动预约提醒.

  • 如果您不能来，请在预约前至少24小时通知诊所.
  • 未能按时赴约可能会导致重新安排的时间延迟.
  • If you are late for your appointment, you may be asked to reschedule.

病人形式

请输入所需资料，然后按“提交”按钮. The fields marked with * are required.

"*" indicates required fields

Patient Information

MM slash DD slash YYYY
性别认同*
Sexual Orientation*
Do you need translation services?*
主要语言*
婚姻状况*
比赛*
种族*
Agricultural Worker*
住房*
Veteran (Have you ever served on active duty military duty?)*
就业/学生
Do you have an advanced directive?*

就业

雇主的地址

紧急联系人

Responsible Party Information

名字*
Address
MM slash DD slash YYYY
性别*

Insurance Information (医疗补助计划, 医疗保险, Private Insurance. Copy of Insurance Cards are Required.)

保险类别*
Do you have insurance that covers you before 医疗保险?
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Your visit today is covered by*

Authorization for Diagnosis and Treatment

Permission is hearby granted for any medical or dental treatment, including but not limited to, x射线, laboratory procedures, 考试, 注射, 牙科手术, including local or general anesthesia, 根据阿米特县医疗服务中心的主治医生或牙医的建议或需要, 公司. or its consulting physicians. All X-Rays will be disposed of after the end of the 7th year. 本诊所有权向任何医疗服务中心提供所要求的病历资料或摘录, third party payers (for billing purposes) and requisite legal, 健康, or social service facility. 我明白，如果我未能支付与我的账户相关的任何余额, I will be required to pay collection fees, 律师费用, or any other costs related to collecting this account. 本人已阅读并明白上述授权书，特此证明.
Authorization for Diagnosis and Treatment

Assignment of Benefits

我在此允许ACMS系统向医疗保险公布任何医疗信息, 医疗补助计划, 或者保险公司需要收到医疗费用, 向本人或病人登记表上的其他人士提供牙科或眼科服务.
Assignment of Benefits

Notice of Privacy Practices

我承认我已经阅读了ACMS系统的隐私政策通知, 说明我的医疗信息如何被使用和披露，以及我如何获得这些信息. 本人可应要求列印私隐惯例或索取私隐惯例通知的副本.
Notice of Privacy Practices
我同意在病历中使用我或我的孩子(或我的法定监护人)的照片, 在无法取得附有照片的法律文件时，作身份证明之用, or for medical reasons. 我明白这些信息将仅用于医疗记录，并将按照ACMS系统的隐私惯例进行处理. 此授权是自愿的，拒绝同意拍照不会影响我在ACMS系统接受的医疗护理.
Photographic Consent

Treatment of a Minor

本人谨此证明，本人具有法定行为能力，可授权为上述指定人士进行上述医疗及/或牙科治疗.
Treatment of a Minor

Patient's Bill of Rights and Responsiblities

我承认我已经阅读并同意ACMS系统的《全国十大赌博官网》. 我可以根据要求打印文件或获取患者权利和责任法案的副本.
Patient's Bill of Rights

Financial Agreement

您在ACMS系统的护理是您和ACMS系统员工之间的伙伴关系. 我们依靠您和您的保险公司支付的费用来维持诊所的运作. We are not responsible for any charges by hospitals, 其他医生, or any other services outside ACMS系统 without prior written consent. For Patient With 没有保险: 我同意 to apply for Sliding Fee Discount as recommended by staff. 我明白，未能提供收入证明并完成流程将导致我负责100%的费用. 我同意，我将在服务时支付我所负责的所有费用或与财务部门作出付款安排. 我明白，如果我未能支付我的账单，ACMS系统有权限制对我的服务.
Financial Agreement - 没有保险
For Patient With Insurance: I understand that ACMS系统 will bill my insurance company. 我同意在每次访问时显示当前的保险信息，并将保险范围的任何变更通知ACMS系统. 我同意在服务时支付我的自付额和所需的免赔额，并支付我的保险计划未涵盖的服务. 如有必要，我将与我的保险公司联系，以确保我所获得的服务得到支付. 我授权ACMS系统或其代表在我的帐户出现拖欠时，按所提供的号码与我联系.
Financial Agreement - With Insurance
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