Medical Patient Registration Forms
Non-School Based Clinics
Medication Mail Out Program
Complete this authorization form to receive your medication by mail.
Mail the paper form to the address below or drop it off at any of our locations.
Access Family Health
Attn: Pharmacy
PO Box 179
Smithville, MS 38870
Dental Patient Registration Forms
School Based Clinic
Patient Registration Forms
SBC patients can register online. Or, print any of the paper forms below and return them to the school.
Sliding Fee Discount Program
Financial Assistance
If approved, you will receive a percentage discount* on services. To apply, fill out these forms and return them to any AFHS clinic.
*Discount based on family size, household income, and Federal Poverty Level (FPL). Proof of income is required. If you have $0 income, there is a Support Form included in the application packet to be filled out by the person who pays your bills/expensees.
A Guide to Medicare Planning
Have you thought about applying for Medicare? Are you not sure how to apply? Are you wondering what all Medicare covers? These a few questions that many people ask when it comes to their decisions about Medicare and Medicare planning. If you would like answers to these questions and a list of steps to help with your medicare planning, click the button below and you will be directed to Care.com’s guide to Medicare Planning.