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Clinic Patient Forms

General Consent to Treat (English)

General Consent to Treat (Spanish)

Patient Information Form (English)

Patient Information Form (Spanish)

Pediatric Patient Information Form (English)

Pediatric Patient Information Form (Spanish)

Authorization for Use and Disclosure of Information (English)

Authorization for Use and Disclosure of Information (Spanish)

About Insurance and Other Financial Arrangements

Charity Form (Spanish)

Insurance & Required Information
If your insurance will pay for services rendered at our clinics, it is our policy to file on your primary and secondary policy. You are responsible for any co-pays, deductibles and non-covered charges required by your insurance company. Our clinics accept cash, checks and major credit cards. Co-payments and deductibles are due at time of service. Always notify the clinic of any insurance or employment changes. Please bring all insurance cards with you, including Medicare or Medicaid. It is your responsibility to know the terms of your insurance coverage, including but not limited to pre-certification requirements, preventive health coverage, non-covered services and your provider’s participation in your insurance plan.


If the services you receive are a result of an automobile accident or are covered by third-party liability insurance, our clinics will look to you for payment in these instances. Payment is due at time of service.
North Mississippi Medical Clinics will await payment from your insurance company for 45 days. During this time, you will not receive a statement asking for expected insurance payments. You will receive a statement reflecting remaining balances due from you. If we do not receive your insurance company’s payment within 45 days, the entire amount of your bill is due from you. You should contact your insurance
company at that time. We will be happy to assist you with following up with your insurer.


North Mississippi Medical Clinics offers several payment options for the part of your bill not covered by insurance, including:

 

  • Payment plan with no interest charge.
  • Extended payment arrangement at Tupelo Service Finance.
  • Financial hardship options for qualified patients.

 

If you have any questions regarding your account or the filing of your insurance, contact our Central Billing Office at 1-800-209-1904. The office is staffed from 8 a.m.-5 p.m. Monday through Friday, but messages can be left 24 hours a day. Information regarding our charity care policy is available upon request.


Advance Directives


What is an Advance Directive?


You have the right to make health care decisions, including decisions about nursing home care, for yourself. Under the law, a patient must consent to any treatment or care received. Generally, if you are a competent adult, you can give this consent for yourself. For you to give this consent, you should be told what the recommended procedure is, why it is recommended, what risks are involved, and what the alternatives are.

 

If you are unable to make your own health care decision, your “advance directives” can be used. An advance directive can be an Individual Instruction or a Power of Attorney for Health Care. For more information, ask a staff member or visit www.nmhs.net/hipaa.php.


Individual Instruction:

 

  • Is a directive concerning a health care decision.
  • Can be written or oral.
  • No specific format. However, end-of-life decisions do have a specific, acceptable form.
  • May be limited to take effect only in specific situations.
  • You should keep a copy. Additional copies should be given to your agent, primary care physician and others as you deem necessary.

 

Power of Attorney for Health Care (PAHC):

 

  • Designates someone as your agent to make health care decisions for you if you are unable to do so.
  • Must specifically authorize your agent to make health care decisions for you and must contain the standard language set out in the law.
  • A specific format is needed, but the PAHC may contain any information you wish to include.
  • You should keep a copy. Additional copies should be given to your agent, primary care physician and others as you deem necessary.
  • If you are unable to make a decision and have not given or prepared an Individual Instruction or PAHC, you may designate an adult of your choice, called a surrogate, to make health care decisions for you. If you do not appoint a surrogate, the members of your family may make decisions for you. If you have an advance directive on file, it is your responsibility to keep your physician informed regarding
    this decision.