Patient Resources
Patient Forms
The physicians and staff at Coastal Health Primary Care look forward to assisting you with your healthcare needs. It is our intention to make your visit as pleasant and convenient as possible. To reduce wait time and facilitate your appointment at any of our 11 area locations, we’ve provided these important forms online for your convenience. Please review the following information, print forms and bring them with you to your next appointment.
Coastal Health Primary Care Financial Policy
This document covers our payment policies and will need to be read and signed upon your first visit.
Coastal Health Primary Care HIPAA Policy
This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully.
Privacy Policy Acknowledgment
Instructions: Please review, sign and bring to your first appointment.
Patient Record of Disclosures
Instructions: Please fill-out and bring to your first appointment.
Patient Medical History Form
Instructions: Please fill-out and bring to your first appointment.
Beneficiary Info Notice
Beneficiary Info Notice (SPANISH)
Voluntary Alignment for Beneficiary
Voluntary Alignment for Beneficiary (SPANISH)
Aetna
- Aetna Commercial (HMO/PPO)
- Aetna Medicare (HMO/PPO)
- Aetna – Medical Mutual
- Aetna (SRC Plan)
- Meritain Health
- WellNet – Aetna
Blue Cross and Blue Shield
- BCBS Federal
- BCBS Medicare (HMO/PPO)
- BlueMedicare Patriot PPO
- BlueMedicare Value PPO
- BCBS of Florida
- BCBS University System of Georgia (GA Offices only)
Cigna
- Cigna
- Cigna APWU
- Cigna Great West
- Cigna Sambra
Humana
Offices can only accept Humana PPO if patients have out of network benefits.
Medicaid
- Amerigroup Medicaid (GA ONLY)
- Clear Health Alliance
- Georgia Medicaid
- Florida Medicaid
- Simply Health Medicaid
- Sunshine Health Medicaid
Medicare/ Medicare Advantage Plans
- Medicare
- Medicare Part B of FL
- Medicare Part B of GA
- Railroad Medicare
- Care Plus Health Plan (Clay and Duval County Only)
- Devoted Health (Specialty Care Only)
- WellMed (Specialty Care Only)
Most Medicare Supplement Plans Accepted
Commercial Plans
- ASR Health Benefits
- Assurant Health/ASA
- AvMed
- GEHA
- Multi Plan Network
- MEDICA
- Oscar
- Ambetter FL PPO
- Ambetter GA PPO
- Allwell (GA Only)
Tricare / ChampVA
- ChampVA
- Tricare For Life
- Tricare Prime
- Tricare Standard (Select)
United Healthcare
- AARP
- United Healthcare Medicare Solutions
- UHC Dual SNP Community Plans
- United Healthcare (Choice / Choice Plus)
- UMR
- Golden Rule
- UHC Student Resources
- United Health Integrated Services
- United Healthcare – All Savers
- United Healthcare – NHP
- United Health One
- United Healthcare
- United Healthcare Oxford
- Optum VA-CCN
Most Major Auto Insurance Plans Accepted
Worker’s Compensation is Case Specific
Department of Labor
Attorney Representation is Case Specific
CONTACT US
Your path to pain relief starts with a conversation
Let’s discuss your pain and your treatment options.
Contact us today to schedule an appointment.