In an effort to make your MEA experience as convenient as possible, we've provided you with the following forms which you can print and fill-out prior to your arrival at any of our clinic locations.


Registration Form

 

Registration Sheet and Consent for Treatment

+ DOWNLOAD REGISTRATION FORM (pdf)

Acknowledgement of Receipt

 

Acknowledgement of Receipt of Notice of Privacy Practices

+ DOWNLOAD ACKNOWLEDGEMENT FORM (pdf)

WC / MVA Form - All patients must fill out

 

Worker's Compensation / Motor Vehicle Accident Form

+ DOWNLOAD WC/MVA FORM (pdf)

Notice of Privacy Practices

 

Copy of our Notice of Privacy Practices

+ DOWNLOAD NOTICE OF PRIVACY PRACTICES (pdf)

Registration Form

 

Registration Sheet and Consent for Treatment

+ DOWNLOAD REGISTRATION FORM (pdf)

+ DOWNLOAD MEA CARES EMPLOYEE ASSISTANCE PROGRAM--INFORMED CONSENT (pdf)

+ DOWNLOAD MEA CARES COUNSELING - INFORMED CONSENT (pdf)

Acknowledgement of Receipt

 

Acknowledgement of Receipt of Notice of Privacy Practices

+ DOWNLOAD ACKNOWLEDGEMENT FORM (pdf)

Notice of Privacy Practices

 

Copy of our Notice of Privacy Practices

+ DOWNLOAD NOTICE OF PRIVACY PRACTICES (pdf)

NOTE: Forms are provided in the Adobe Acrobat format.
+ Download Adobe Reader.

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MEA Administrative Office | 308 Corporate Drive Ridgeland, MS 39157
Phone (601) 898-7500 | Fax (601) 898-7577