Becoming a Patient

Click here to Request an Appointment

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.

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.

Patient Forms

Please enter the information requested and then click on the "Submit" button. The fields marked with * are required.
Patient Information
*Primary Language
*Do you need translation services?
*Marital Status
*Agricultural Worker
*Veteran (Have you ever served on active military duty?)
Emergency Contact
Responsible Party Information
Insurance Information (Medicaid, Medicare, Private Insurance. Copy of Insurance Cards are 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"

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.

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.

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 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.

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.

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.

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.

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.