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 (Medicare PPO & HMO)
- Aetna Commercial (PPO & HMO)
- Aetna (PPO & HMO Commercial plans)
- Aetna (SRC Plan)
- Meritain Health
- WellNet – Aetna
- Aetna – Medical Mutual
- Aetna Continental Life Insurance Co
- Aetna Medicare Supplement
Auto Insurance
- All State
- Amica
- Assurance
- Auto Club Ins FL
- Auto Owner’s Insurance
- Blue Star Claims Management
- Bristol West (Foremost Insurance)
- Dairy Land
- Mitchell Direct General
- Esurance
- Farmers
- Farm Bureau
- Gainsco
- Geico
- Infinity
- Kemper Auto
- Liberty Mutual
- Mendota
- Metlife
- Metropolitan
- Mercury
- Nationwide
- Occidental
- Ocean Harbor Casualty
- Peach Tree
- Permanent General Auto
- Preferred Mutual
- Progressive
- Pronto Insurance
- Safeco
- State Farm
- Travelers
- USAA
Blue Cross and Blue Shield
- BCBS Federal
- BCBS of Medicare HMO
- BCBS of Medicare PPO
- BlueMedicare Patriot PPO NEW
- BlueMedicare Value PPO NEW
- BCBS of Florida Medicare HMO Plus
- BCBS of Florida (BlueCare, BlueCard, BlueOptions)
- BCBS University System of Georgia (St. Mary’s Office only)
- BCBS Ascension (SmartHealth)
- BCBS (Baptist Health)
- *BCBS (Gator Care)
*(3 Tier Product) Tier 1: PRIMARY CARE ONLY. (Aboushaar, Hardin, Goh, Braeutigam, Caballero, Harris, Pennington).
Tier 2: PAIN DOCTORS ONLY. This does not include extenders. Tier 2 coverage benefits available = higher patient cost share.
Tier 3: OUT OF NETWORK
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