Patient Registration

Prepare for Your Visit

Patient Registration Form

Please enter the information requested below and then click on the “Agree and Submit” button.

    Patient Information

    Contact Information

    Personal Information

    Emergency Contact

    Work Information

    Income of patients at the Health Center is a Federal reporting requirement. Thank you for providing this information.

    Responsible Party Information

    Insurance Information (Medicaid, Medicare, Private Insurance card is required)

    Authorization for Diagnosis and Treatment

    I hereby consent to the medical, dental, or optical examination, treatment, and procedures which may be performed during the office visits, including but not limited to lab work, x-rays, exams, injections, immunization, dental fillings, extractions and anesthesia, local or general, as may be ordained advisable or necessary by the attending physician, advanced registered nurse practitioner, physician assistant, dentist and optometrist of Coastal Family Health Center (CFHC) or by their consulting physicians, dentists and optometrists.

    I agree *

    Assignment of Benefits

    I hereby give permission to CFHC to release any medical information to Medicare, Medicaid, or the insurance company that is needed to receive payment for medical, dental or optical services rendered to me or other persons listed on the patient registration form.

    I agree *

    Photo Release

    I hereby consent to have photograph made of me or my child (or person for whom I am legal guardian) to be used in medical record, for purposes of identification when a legal document with photo identification is not available, or for medical reasons. I understand that this information will be used in medical records only and will be treated consistently with CFHC's privacy practices. This authorization is voluntary and refusal to consent to photographs will not affect the medical care I will receive at CFHC.

    I agree

    Financial Section

    Your care at CFHC is a partnership between you and the staff of CFHC. We rely on the fees paid by you and your insurance company to keep the clinics operating. We are not responsible for any charges by hospitals, other physicians, or any other services outside CFHC.

    For Patient with No Insurance

    I agree to apply for Sliding Fee Discount as recommended by CFHC staff. I understand that failure to provide proof of income and complete the process will result in my being responsible for 100% of charges. I agree that I will pay all charges for which I am responsible at the time of service or make payment arrangements prior to arrangement of service. I understand that if I fail to pay my bill, CFHC reserves the right to limit services to me.

    I agree

    For Patient with Insurance

    I understand that CFHC will bill my insurance company. I agree to show current insurance information at each visit and notify CFHC with any changes in coverage. I agree to pay my co-payment and required deductible at the time of service and to pay for services not covered by my insurance plan. I will contact my insurance, if necessary, to ensure payment for services that I have received.

    I agree

    By submitting this form you acknowledge that all of the information entered is true and correct, and that you have read and agree with the above consent and agree to its terms.

    Our patients are part of the family and encouraged to be active partners for managing their health and building healthy communities.

    • Call to make an appointment at 877.374.4991 or fill out a request for an appointment here.
    • Check Locations for specific hours at each health center
    • Arrive 15 minutes before the appointment (30 minutes for new patient registration) to help us keep your information accurate and up-to-date, so you can see your provider in a timely manner.
    • You can also fill out Patient Registration Form in advance to facilitate your registration as a new patient.

    Please bring the following documents on your visit:

    • All payments, co-payments, deductibles, or co-insurance
    • Valid Photo ID
    • Current Proof of income (if applying for sliding fee) and residency
    • Insurance card(s), including Medicaid and Medicare at every visit
    • For your children, please bring immunization record
    • Current list of medications

    We value your appointment and will call to confirm it the day prior to your scheduled time.
    Please notify the clinic at least 24 hours prior to appointment if you are unable to come.
    Failure to keep your appointment may result in a delay of rescheduling.
    If you are late for your appointment, your medical provider may ask that you reschedule