MEA – Forms

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)

Notice of Privacy Practices
Copy of our Notice of Privacy Practices
+ DOWNLOAD NOTICE OF PRIVACY PRACTICES (pdf)
+ DESCARGAR AVISO DE PRÁCTICAS DE PRIVACIDAD (pdf)

Authorization To Release Medical Records
+ DOWNLOAD AUTHORIZATION TO RELEASE MEDICAL RECORDS (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)

Notice of Privacy Practices
Copy of our Notice of Privacy Practices
+ DOWNLOAD NOTICE OF PRIVACY PRACTICES (pdf)
+ DESCARGAR AVISO DE PRÁCTICAS DE PRIVACIDAD (pdf)

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

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