Please complete this form to describe your practice. If you are applying as a non-sponsor (no fee), complete only the top part of the form and include a brief description of your major areas of interest or expertise. To become a sponsor ($95/year) you should complete the entire form, providing as much detail as possible. Send an additional email message if more room is needed. (Note: You will have an opportunity to modify the details after the page is set up and before your are billed for the service.)  To see an example of a Sponsor page, click here, then use the BACK button on your browser to return and complete the application form.

Type of application: sponsor ($95/year) or nonsponsor (free):
Your Full Name:
Your email address:
Profession:
Type of Degree:
Licensed in  Mississippi (Yes/No):
Type of License:
Office Phone:
Office Address:
Do you want to  participate in the  MMHR professional  discussion group? (Yes/No):
Areas of Special Interest  or Expertise: (please describe in detail)
Non-Sponsors please stop here, and press the "Click here when finished" button at the bottom of the form.  Sponsors please continue filling out the form.
Graduated From:
Year Graduated:
Years in Practice:
Current Practice/ Place of Employment:
Types of Treatment Offered: (please describe in detail)
Hospital Affiliations:  (please list)
Typical Fees:
Types of Insurance  accepted:
Accepts Direct Billing  to Insurance Companies  (Yes/No):
Accepts Medicare/ Medicaid (Yes/No):
Affiliated with any  Managed Care  Organizations (list):
Directions to Office:
Office Hours:
Your Internet  Homepage URL:
Other Information: