New Appointment Form

If you selected yes to any of the preceeding question, please call 911 or go to your nearest hospital emergency room immedicately. 

I voluntarily consent to receive medical and health care services provided by H.E.A.L. Mississippi physicians, nurse practitioners, employees and such associates, assistants, and other health care providers. I understand that such services may include diagnostic procedures, examinations, health education, dietary assessments/counseling, lifestyle medicine, healthy lifestyle behavioral coaching and other prescribed necessary health/medical treatment. I acknowledge that H.E.A.L. Mississippi may use health information exchange systems to electronically transmit, receive and/or access my medical information which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history, and other health care information. I understand that this Consent to Treatment/Health Care Agreement will be valid and remain in effect as long as I attend or receive health care services from H.E.A.L. Mississippi, unless revoked by me in writing with such written notice provided to the clinic from which I receive services.

This Notice of Privacy Practices is NOT authorization. This Notice of Privacy Practices describes how we, H.E.A.L. Mississippi, our business associates and their subcontractors, may use and disclose you protected health information (PHI) to carry out treatment, payment or healthcare operations and for other purposes permitted by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including information that may identify you and information that may relate to your past, present, and future health conditions and related healthcare services.

To review, please click here: https://healmississippi.com/hippa/

In consideration for receiving medical or health care services, I hereby assign to H.E.A.L. Mississippi my right, title, and interest in all insurance, Medicare/Medicaid, or other third-party payer benefits for medical or health care services otherwise payable to me. I also authorize direct payments to be made by Medicare/Medicaid and/or my insurance company or other third-party payer, up to the total amount of my medical and health care charges, to H.E.A.L. Mississippi. I certify that the information I have provided in connection with any application for payment by third-party payers, including Medicare/Medicaid, is correct.

I agree to pay all charges for medical and health care services not covered by Medicare/Medicaid, my insurance company, or other third-party payer, and agree to make payment as requested, (i.e. copays, deductible, coinsurance, etc.)

I hereby authorize H.E.A.L. Mississippi to charge my credit/debit card above for the agreed upon services.