Online Registration

Call Us: (850) 231-9286

Coastal Family Practice

and Acute Care Center, LLC.

Social History: Alcohol Use *

Often

Sometimes

Never

Past Use

Marital Status

Single

Married

Divorced

Widowed

Birth Date *

Emergency Contact Phone

Authorization for Treatment: I authorize Coastal Family Practice and Acute Care, LLC to perform procedures and treatment including the administration of medicine and local anesthetics along with other surgical and medical procedures that may be medically necessary. *

Name of Secondary Insurance Company (if applicable)

Mobile Phone

Collection Agencies: In the event that your account is placed with a Collection Agency, a collection fee may be added to your account and shall become part of the total amount due. You will be responsible for any and all cost of collection including attorney fees and court costs. You agree that in order for us to service your account or to collect any amount you may owe, we and our collection agencies may contact you by telephone at any telephone number associated with your account, including wireless telephone, which could result in charges to you. We and our collection agencies may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. *

If yes, Please describe

Zip Code *

How were you referred to our office

Gender Identity (Optional Question)

Male

Female

Female-to-Male (FTM)/Transgender Male/Trans Man

Genderqueer, neither exclusively male nor female

Male-to-Female (MTF)/Transgender Female/Trans Woman

Address *

Date of last Pneumonia Vaccine?

Name: *

Assignment of Benefits: I authorize the direct payment to Coastal Family Practice of any sum I now or hereafter owe the clinic by any insurance company obligated to reimburse me, and to my attorney, out of proceeds of any settlement of my case for the charges for services rendered or otherwise obligated to make payment to me or Coastal Family Practice based in whole or in part upon the charges made for services rendered. In the event any insurance company obligated by contractual agreement to make payment toCoastal Family Practice or me for the charges made for services refuses to make sure payment upon demand by the clinic, I hereby assign and transfer to Coastal Family Practice the cause of action that exists in my favor against any such company. I authorize Coastal Family Practice to prosecute said action either in my name or the name of the clinic as it deems necessary, and further authorize Coastal Family Practice to compromise, settle or otherwise resolve said claim as it deems necessary. *

Office Number

Social History: Caffine *

Often

Sometimes

Never

Past Use

Date symptoms appeared or accident happened

Social Security #

What medications, drugs, or supplements are you taking and what are the dosages?

Women: Date of first day of last menstrual period?

Date of last Covid Vaccine?

Sex *

Male

Female

Chief Complaint: Purpose of this appointment *

Member Number

Date of last Physical Exam?

Date of last Tetanus Vaccine?

Social History: Tobacco Use *

Often

Sometimes

Never

Past Use

Are you currently under the care of any other doctors for any medical problems. If yes, whom and for what medical problems?

Women: Number of Miscarriages?

State *

Home Phone

Women: Number of Live Births?

Assignment of Benefits/Authorization: I hereby acknowledge that I am receiving (or about to receive) health care services from Coastal Family Practice, and that the clinic providing the services is willing to wait for payment for the services, provided that there continues to be a reasonable change that payment will be made either by insurance proceeds or out of the settlement of a liability claim. *

Date of last Colonoscopy?

Women: If yes, How many weeks?

Secure Online Registration

ELECTRONIC SIGNATURE ACKNOWLEDGEMENT AND CONSENT: I agree and understand that by signing this Electronic Signature and Consent that all electronic initials and signatures I input to this form are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions. BY SIGNING BELOW, I ACKNOWLEDGE I HAVE READ AND UNDERSTAND ALL THE ABOVE. *

If you are a minor, of if you are being represented by another party,

Cancellation and No Show Policy: Office appointments, which are canceled with less than 24 hour notice, may be subjected to a $25 cancellation fee. If no call no show happens twice in a 12 month period may be dismissed from the practice and denied future visits. We understand that special situations are unavoidable and the fees may be waived with management approval. *

Check here to receive email updates

Occupation

Consent to email/text messages for appointment reminders and other healthcare communications: Patients in our practice may be contacted via email or text messages to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and provide general health reminders/information. I consent to emails and text messages to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing.

Women: Date of last Mammogram?

Member Id

Emergency Contact Relation

Women: Are You Pregnant?

Yes

Social History: Drug Use *

Often

Sometimes

Never

Past Use

Do you have a Living Will?

Yes

No. I would like information on them

Financial Agreements: If an insurance company obligated to pay me or Coastal Family Practice the charges for services rendered refuses to pay upon demand by the clinic, or if there is no insurance company so obligated, then I will pay for services rendered by Coastal Family Practice. I will pay my account in full immediately, or I will keep my account current. If I have a liability claim and my attorney refuses to protect the interest of Coastal Family Practice, or if I have not engaged the services of an attorney, I hereby promise to pay my bill in full within ten (10) days from the date my liability claim is settled or after the passage of two (2) months from the date of my last treatment, whichever comes first. *

Emergency Contact

Employer

HIPAA Notification- THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. During your care as a patient at Coastal Family Practice, we may use or disclose personal and health related information about you in the following ways: * Your personal health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment. * Your health care records, as well as, your billing records may be disclosed to another party, such as insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for the payment of your services. * Your name, address, phone number, and your health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. If you are not home to receive an appointment reminder, a message may be left on your answering machine. Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization, it will not affect the care provided to you or the reimbursement avenues associated with your care. Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in the following circumstances. * If we are providing health care services to you based on the orders of another health care provider. * If we provide health care services to you in case of an emergency. * If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so. * If we are ordered by the courts or another appropriate agency. Any use or disclosure of your protected health information, other than is outlined above, will only be made upon your written consent. We normally provide information about your health to you in person at the time you receive care from us. We may also mail information to you regarding your healthcare or about the status of your account. If you would like to receive this information at an address other than your home, or if you would like the information in a different form, please advise us in writing as to your preferences. You have the right to inspect and/or copy your health information for seven years from the date that the record was created or if the information remains in our files. In addition, you have the right to request an amendment for your health information. Requests to inspect, copy or amend your health-related information should be provided in writing. We are required by the state and federal law to maintain the privacy of your patient file and the protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by the law to abide by the terms of these notices while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy practices, we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and no longer be protected by federal rules. If you have a complaint regarding our privacy notice, our privacy practices, or any aspect of our privacy activities, you should direct your complaint to Robert Marshall, office manager. If you would like further information about our policies and practices, please contact us. This notice is effective as of 01/02/2022. This notice and any alterations or amendments made herein will expire seven (7) years after the date the record was created. My signature acknowledges that I can request a copy of the HIPPA Notice and it will be provided to me. *

Men: Date of last prostate exam?

Women: Date of Last Pap

Personal Health History: General Comments. Please list any medical conditions not covered above or if you would like to supply more medical history / information.

Are you allergic to any medications?

Yes

Social History: Exercise *

Often

Sometimes

Never

Date of last Flu Vaccine?

Disclosures to Friends and/or Family Members: I give my permission for my protected health information to be disclosed for purposes of communicating results, findings, and care decisions to the following people:

Name of Primary Insurance Company

City *

Please fill out the information on this page and click the submit button at the bottom. Do not leave this page or reload. You will lose all of your entries and will have to start over. Questions that do not apply to you can can be left blank. Once you click Submit please scroll back to the top of the page and you will receive confirmation that your registration has been submitted

Once you have submitted your registration our staff will reach out to you to make your appointment. Please present your insurance and id card to our reception desk during your first appointment.

Date and time

Employer Address

Have you had any surgeries? If yes, what and when?

Do You Have Health Insurance:

Yes

Women: Contraception type

Date of last Shingle Vaccine?

Women: Number of Pregnancies?

Authorization to File Insurance: I authorize Coastal Family Practice to release any information it deems appropriate concerning my physical condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred for services rendered to me by Coastal Family Practice or any member of the staff acting on the clinic’s behalf. *

General Comments: Please enter any information you want to share that was not covered in this form (more medical info, comments, recommendations etc.)

Women: Number of Abortions?