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    • Optometry
    • Lab
    • HIV Counseling Screening
    • Mental Health, Behavioral, Substance Abuse
  • What's New
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  • FAQs
  • Contact Us
PATIENT PORTAL
  • Home
  • About Us
    • Staff
    • Board Of Directors
    • History
    • Careers
      • Job Announcement
      • Job Announcement
    • Human Resources
      • Human Resource Officer
    • Support
  • Patients & Visitors
    • Patient Portal
    • Becoming a Patient
    • Locations
    • Sliding Fee
    • Patient Assistance
    • Satisfaction Survey
    • Forms
  • Our Services
    • Adult Internal Medicine and Family Practice
    • After Hours Access
    • Affordable Health Insurance
    • Mississippi Shine Project
    • Pediatrics
    • Womens Health
    • WIC Program
    • Preventative Dental Care
    • Optometry
    • Lab
    • HIV Counseling Screening
    • Mental Health, Behavioral, Substance Abuse
  • What's New
  • Community Partnerships
  • FAQs
  • Contact Us

Forms

Note: These forms are in the PDF format. Click here to download the free Adobe reader program.

Forms

  • Patient Registration Form
  • General Consent Form
  • Sliding Fee Application Form
  • Patient Update card
  • Patient Satisfaction Survey
  • HIPAA Privacy Practice
  • Patient’s bill of rights and responsibilities

Other JCHC Forms

  • Verification of No Income
  • Letters to Department of Human Services
    • Jefferson County
    • Franklin County
    • Amite County
    • Claiborne County
    • Adams County
    • Wilkinson County
  • Medicare Questionnaire Follow-up Attachment
  • Proof of Income Notification

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