Patient Registration LocationACMSPCMSLDSFirst Name(Required) Middle Last Name(Required) Date of Birth(Required) MM slash DD slash YYYY Marital StatusMarriedSingleWidowedDivorcedSocial Security Number(Required) Address Home PhoneCell PhoneCity StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip County District Email Patient EthnicityAre you of Hispanic or Latino Decent? Yes No Unknown/Unreported Patient RaceCheck only one African American (Black) Caucasian (White) Natice American/Alaskan Asian/Pacific Islander Native Hawaiian Other Pacific Islander Multi-Racial Unknown Gender Identity Male Female Transgender/Female-to-Male Transgender/Male-to-Female Other Choose not to disclose Sexual Orientation Straight or heterosecual Bisexual Lesbian, Gay or Homosecual Something else Don't know Choose not to disclose Emergency Contact Relationship TelephonePatient's Employer's Name Address TelephoneInsurance Carrier Policy # Account # Pharmacy Used Pharmacy TelephoneGuarantor Responsible for Payment Date of Birth MM slash DD slash YYYY Social Security # Account Relationship Guarantor's Physical Address Mailing Address Guarantor's Employer's Name Address TelephoneAuthorization for Care and Patient Account Policy Permission is hereby granted for any care, treatment, testing and all other services, 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 health care provider at Amite County Medical Services, Inc. or its consulting health care providers. 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.ACMS Representative Signature of Patient or Responsible Adult(Required) Date MM slash DD slash YYYY Relationship of Person Signing for Patient You may be eligible for a discount on the services rendered at this clinic.Please check below to indicate whether you do or do not wish additional information. I wish to have additional information. Yes No Do you have an advance directive? Yes No Are you a veteran? Yes No Are interpretation services needed? Yes No Are you homeless? Yes No Are you a migrant or seasonal agricultural worker? Yes No Do you live in public housing? Yes No Assignment of Benefits: Medicare, Medicaid and Other Third PartiesMedicare I.D. Number Medicaid Beneficiary Number I request that payment of authorized Medicare, Medicaid and other third party benefits be made on my behalf to Amite County Medical Services, Inc. I authorize any holder of medical records or the information about me to release to the Division of Medicaid or the Fiscal Agent any information needed to determine these benefits or the benefits payable for related services.Beneficiary's Signature Date MM slash DD slash YYYY The following information will be used for reporting purposes only. Please help us document the community need for the services provided to you by Amite County Medical Services, Inc. Thank YouPlease choose the number that live in your house(Required)Please Choose12345678910Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 1 person lives in your house 0-$12,490 $12,491-$17,486 $17,487-$19,984 $19,985-$24,980 OVER $24,981 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 2 people live in your house 0-$16,910 $16,911-$23,674 $23,675-$27,056 $27,057-$33,820 OVER $33,821 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 3 people live in your house 0-$21,330 $21,331-$29,862 $29,863-$34,128 $34,129-$42,660 OVER $42,661 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 4 people live in your house 0-$25,750 $25,751-$36,050 $36,051-$41,200 $41,201-$51,500 OVER $51,501 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 5 people live in your house 0-$30,170 $30,171-$42,238 $42,239-$48,272 $48,273-$60,340 OVER $60,341 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 6 people live in your house 0-$34,590 $34,591-$48,426 $48,427-$55,344 $55,345-$69,180 OVER $69,181 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 7 people live in your house 0-$39,010 $39,011-$54,614 $54,615-$62,416 $62,417-$78,020 OVER $78,021 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 8 people live in your house 0-$43,430 $43,431-$60,802 $60,802-$69,488 $69,489-$86,860 OVER $86,861 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 9 people live in your house 0-$47,850 $47,851-$66,990 $66,991-$76,560 $76,561-$95,700 OVER $95,701 Please Indicate the approximate amount of the gross yearly income for your householdYou indicated 10 people live in your house 0-$52,270 $52,271-$73,178 $73,179-$83,632 $83,633-$104,540 OVER $104,541 Please Complete if the Patient is a MinorI do hereby certify that I have the legal capacity to authorize medical and/or dental treatment for the above named individual as described above.Other adults authorized to bring the minor for treament: (1) (2) ACMS Representative Signature of Authorized Adult Date MM slash DD slash YYYY Relationship to Patient Amite County Medical Services, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sec. "This institution is an equal opportunity provider, and employer."CAPTCHANameThis field is for validation purposes and should be left unchanged.
