MEA – Forms

Registration Form
Registration Sheet and Consent for Treatment
+ DOWNLOAD REGISTRATION FORM (pdf)

Notice of Privacy Practices
Copy of our Notice of Privacy Practices
+ DOWNLOAD NOTICE OF PRIVACY PRACTICES (pdf)

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

MEA Administrative Office P.O. Box 1998, Madison, MS 39130
Phone (601) 898-7500 | Fax (601) 898-7577

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