Welcome to the PATH

Welcome to the PATH

Pre-Exposure Prophylaxis Access to Treatment at Home
Coastal Family Health Center is excited to offer this online journey to receive your PrEP prevention medication from the comfort of your home.

The PATH is as easy as one-two-three:
1. Register with Us
2. Register for Labs
3. Meet with Telehealth Providers
Name*

First NameLast Name
Nickname
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

WELCOME

POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION.We create a record of the care and services you receive at Coastal Family Health Center. We need this record in order to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Coastal Family Health Center, whether made by Center personnel or by your personal doctor. This law requires us to: make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; and to follow the terms of notice that are currently in effect. Other ways we may use or disclose your protected healthcare information include: appointment reminders; as required by law; for health related benefits and services; to individuals involved in your care or payment for your care; research; to avert a serious threat to health or safety; and for treatment alternatives. Other uses and disclosures of your personal information could include disclosure to, or for: coroners, medical examiners and funeral directors; health oversight activities; law enforcement; lawsuits and disputes; military and veterans; national security and intelligence activities; organ and tissue donation; and others; public health risks; and worker’s compensation.
Yes, I understand and accept*

Have you ever been diagnosed with HIV?*

YesNo
Have you or are you currently taking PrEP?*

YesNo
Here's a few facts about PrEP: PrEP is 99% effective when used daily. PrEP reduces but does not eliminate the chance of acquiring HIV. PrEP does not prevent pregnancy, and PrEP does not prevent other sexually transmitted diseases.*

Yes, I understand

Are you currently taking any medications, herbal treatments like St. John's wort or nutritional supplements such as creatine?*

YesNo
Please Explain
Do you have any drug allergies?*

YesNo
Please Explain
Do you have any questions, or is there anything else we should know?*

YesNo
Please Explain

Insurance
Do you have insurance?*

YesNo
We need the following information, or a photo of the front and back of your insurance card. If you like, you can provide this later, but we won't be able to fulfill your prescription without this information. If you have multiple cards (e.g. a separate pharmacy benefit card), be sure to upload a picture of both. We will bill your insurance for the medication, and if necessary, enroll you in one of the drugmakers' patient assistance programs to cover any out-of-pocket costs. Your insurance will not be billed for the doctor consultation or the required labs.
Insurance Company Name*
Member ID Number*
BIN*
PCN*
Group Number*
*upload picture of front of insurance card*

Cancelof
*upload picture of back of insurance card*

Cancelof
Add second insurance information
Insurance Company Name*
Member ID Number*
BIN*
PCN*
Group Number*
*upload picture of front of insurance card*

Cancelof
*upload picture of back of insurance card*

Cancelof
Patient Assistance Program Information

You're not alone on this PATH to prevention-your Coastal family has team members ready to help enroll you into a patient assistance program that can greatly reduce the cost of PrEP depending on your needs. We just need some financial information!
*Please note, in order to qualify for PrEP at no cost, you must not earn more than $62,450 annually. This informationis confidential and is only shared with patient assistance programs and no credit checks are performed.
Last four digits of your Social Security Number*
Annual Household Income*
Number of People in Household*
Have you applied for Medicaid?*

YesNo
Are you eligible for VA benefits?*

YesNo

Congratulations!

Your walk on the PATH to PrEP is almost complete. Now we just need you in for labs!
Which location would you prefer to attend?*
Which appointment time do you prefer?*

Early morningLate morningEarly afternoonLate afternoon
Where would you like us to fill you prescription?*

Coastal Family Health Center Pharmacy - GulfportCoastal Family Health Center Pharmacy - BiloxiMail OrderOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: