Our patients are part of the family and encouraged to be active partners for managing their health and building healthy communities.

  • To make an appointment with the Shubuta clinic, call 601-687-1391 and to make an appointment with the Jasper clinic, call 601-787-3464.
  • Check Locations (link to location) for specific hours at each health center.
  • Arrive 15 minutes before appointment (30 minutes for new patient registration) to help us keep your information accurate and up-to-date, so you can see your provider in a timely manner.
  • You can also fill out "Patient Registration Form" in advance to facilitate your registration as a new patient.

Our patients are part of the family and encouraged to be active partners for managing their health and building healthy communities.

  • Photo ID
  • Proof of income and address (2 weekly or bi-weekly paycheck stubs)
  • Insurance card(s), including Medicaid and Medicare at every visit
  • For your children, please bring immunization record
  • Current medications
  • Copayment or sliding fee costs (Minimum of $25 on first visit for Medical) - (Minimum of $30 on first visit for Dental). There will be an additional charge for Lab and X-Ray, etc.

We value your appointment and will call to confirm it the day prior to your scheduled time.

  • Please notify the clinic at least 24 hours prior to appointment if you are unable to come.
  • If you are 15 minutes late for your appointment, you will be deemed as a "walk in" patient.
Patient Information
First Name:
MI
Last Name
PatientID
Street Address
City
State
Zip Code
County
Home Phone
Social Security Number
Email
Sex/Gender

Female Male

Date Of Birth
Primary Language

English Spanish French Arabic Other

Would you like an interpreter?

Yes No

Marital Status

Married Single Divorced Widowed Separated Partner

Race

Black/African American Asian American Indian/Alaskan Native White Native Hawaiian Other Pacific Islander More than 1 race

Ethnicity

Not Hispanic/Latino Hispanic/Latino

Agricultural Worker

Seasonal Migrant Not Applicable

Housing

Permanent Residence Shelter Transitional Doubling Up Street Other

Disabled

Yes No

Date Disabled
Veteran

Yes No

Emergency Contact
Name
Phone
Relationship
Work Phone
Cell Phone
Employer Name
Employer Address
Employer City
Employer State
Employer Zip

Income of patients at the Health Center is a Federal reporting requirement. Thank you for providing this information.

Total Annual Income
Number of People in Your Household
Employment/Student

Full Time Student Part Time Student Full Time Part Time Unemployed Self-Employed Military Active Duty Retired

Responsible Party Information
First Name:
MI
Last Name
Relationship to Patient
Street Address
City
State
Zip Code
Phone
Social Security Number
Date Of Birth
Email
Sex/Gender

Female Male

Insurance Information (Medicaid, Medicare, Private Insurance card is required)
Type of Insurance

No Insurance Medicaid Private Insurance (Complete Information Below) Medicare

Do you have an insurance that covers you before Medicare?

Yes No

Medicare Supplement Name
Medicare ID
Primary Insurance
Primary Insurance CoPay
Primary Insurance
Group/Policy #
Primary Insurance ID #
Secondary Insurance
Secondary Insurance CoPay
Secondary Insurance Group/Policy #
Your visit today is covered by

Workman's Compensation Liability Insurance Not Applicable

Authorization for Diagnosis and Treatment

I hereby consent to the medical, dental, or optical examination, treatment, and procedures which may be performed during the office visits, including but not limited to lab work, x-rays, exams, injections, immunization, dental fillings, extractions and anesthesia, local or general, as may be ordained advisable or necessary by the attending physician, advanced registered nurse practitioner, physician assistant, dentist and optometrist of JCHC or by their consulting physicians, dentists and optometrists.

I agree

Assignment of Benefits

I hereby give permission to JCHC 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.

I agree

Notice of Privacy Practices

I acknowledge that I have reviewed JCHC'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 obtain a copy of the Notice of Privacy Practices upon request.

I agree

I hereby consent to have photograph made of me or my child (or person for whom I am legal guardian) to be used in 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 and will be treated consistently with JCHC's privacy practices. This authorization is voluntary and refusal to consent to photographs will not affect the medical care I will receive at JCHC.

I agree

Patient's Bill of Rights and Responsibilities

I acknowledge that I have reviewed and agreed with JCHC Patient's Bill of Rights and Responsibilities. I may obtain a copy of Patient's Bill of Rights and Responsibilities upon request.

I agree

Financial Agreement

Your care at JCHC is a partnership between you and the staff of JCHC. 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 JCHC.

For Patient with No Insurance:

I agree to apply for Sliding Fee Discount as recommended by JCHC staff. I understand that failure to provide proof of income and complete the process will result in my being responsible for 100% of changes. I agree that I will pay all charges for which I am responsible at the time of service or make payment arrangements with the Collection Department. I understand that if I fail to pay my bill, JCHC reserves the right to limit services to me.

I agree

For Patient with Insurance:

I understand that JCHC will bill my insurance company. I agree to show current insurance information at each visit and notify JCHC 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 agree

By submiting this form you acknowledge that all of the information entered is true and correct, and that you have read and agree with the above consent and agree to its terms.