Patient Registration 2025

Patient Registration 2025
Select the type of location for your visit:

Main ClinicSchool Location
Select the location where the patient will be seen:*
Select the location where the patient will be seen:*
Patient Name:*

First NameLast Name
Social Security Number:
DOB:*

MonthDayYear
Date
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Primary Contact Email:*
example@example.com
Preferred Contact Method
Can we leave a detailed voice message?

YesNo
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address (if different than mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex:
Marital Status:
Mother's Maiden Name:
Student Status:
Preferred Language:
Other Language:
Race:
Ethnicity:
Do you need an Interpreter?

YesNo
Do you need transportation assistance?

YesNo
Select any that apply:

Migrant Farm WorkerSeasonal Farm WorkerCFHC EmployeeCFHC Employee Family
Employment Status:
Employer Name, if Applicable:
Are you a veteran?
Housing Status:
If other is selected, please explain:
Race:
Ethnicity:
If other is selected, please explain:
Emergency Contact
Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Relationship:
If other is selected, please explain:
Would you like to apply for the Sliding Fee Discount Program?

YesNo
Total Annual Household Income
Number of people in household dependent on Total Household Income
I agree to allow Coastal Family Health Center to contact me reguarding my private health information, evaluation and treatment.
Name of Individual Giving Authorization:*
Date of Birth*

MonthDayYear
Signature:*

Clear
Date:*

MonthDayYear
Signature Date
Witness Name:
Witness Signature:

Clear
Date:

MonthDayYear
Signature Date

Sliding Fee Discount Program Application
Please list the names of the members of your household with their income and relationship to you.

Your household is those people that are dependent on the total household income. If there are more than eight people in your household, please ask the front desk for an additional form.
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Income:
Frequency:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Income:
Frequency:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Income:
Frequency:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Income:
Frequency:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Income:
Frequency:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Income:
Frequency:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Income:
Frequency:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Income:
Frequency:
Total Number of People in Patient Household:
Total Household Income:
Do you have proof of income available today?

YesNo
Acceptable documents for proof of income:

Most recent tax return

Social Security/Pension Statement

Unemployment Benefit Statement

Disability Benefit Statement

Child Support

Most recent paystub with hourly rate or last four for calculating average

Public Assisstance Doucmentation (DHS, Medicaid, Section 8)

Letter of Support/Employer Letter (ask to speak to Registrar)

Self-attestation form (ask to speak to Registrar)

Alimony

I attest that the information stated above is true and accurate.
Name of Individual completing the form:

First NameLast Name
Signature:

Clear
Date:

MonthDayYear
Date
Relationship if other than patient:

End
Medical Insurance Information
Primary Medical Insurance:
Insurance Policy Information:

Policy Number:Group Number:
Name of Insured:
Date of Birth of Policyholder:

MonthDayYear
Date
Policy Holders Name:
Relationship to Insured:

SelfSpouseParentGuardian
Secondary Medical Insurance:
Insurance Policy Information:

Policy Number:Group Number:
Responsible Party
Responsible Party:
Date of Birth:

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Is the patient under the age of 18 years old?

YesNo

Authorization of Consent for Treatment of a Minor
I <Your Name> , authorize the following individual(s) to consent to the evaluation and treatment of my child,<Patients Name> for services offered by Coastal Family Health Center:
Name:

First NameLast Name
Relationship
Name:

First NameLast Name
Relationship
Name:

First NameLast Name
Relationship
Note: Person(s) to whom you authorize consent to treatment of minor is delegated to be at least 18 years of age.
Unauthorized services: (Check all that apply)

Medical assessment, diagnosis & treatmentImmunizationsLaboratory testsDental Evaluation & treatmentOptometry evaluation & treatmentBehavioral health servicesOther
This authorization will remain effective until:
Date or one-time even: <Insert Date> unless I revoke it earlier.
*All authorizations without a date will be renewed every two years. Patient reserves the right to revoke authorization prior to the two-year renewal.*

Note: You may revoke this authorization in writing at any time.
Name of Parent/Guardian (Please Print)

First NameLast Name
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
* Coastal Family Health Center is a Title X provider. As a Title X provider, minors are allowed to receive family planning services, including contraceptive services, STD testing & treatment, HIV testing and pregnancy options counseling based on their own consent and on a confidential basis.

END MINOR CONSENT
Mother's Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.
Father's Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.
Guardian's Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.
HIPAA Authorization - Consent to Disclose Protected Health Information (PHI)
I, Insert Your Name give my permission to Coastal Family Health Center, Inc. to disclose and release my Protected Health Information described below to:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship:
Health Information to be disclosed:

My complete health record (including but not limited to diagnoses, lab test or results, prognosis, treatment plan, appointments and billing for all conditions)My complete health record as above, with the exception of the following information:
Check all that apply:

Mental Health TreatmentCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOther
Form of disclosure to the above listed person(s): (Check all that apply)

Verbal (telephone or in person)Printed documentsElectronic or digital transmission (email or fax)
This Authorization shall remain in effect until: blanks unless I revoke it earlier.
* All other authorizations will be renewed annually. Patient reserves the right to revoke authorization prior to annual renewal. NOTE: You may revoke this authorization at any time.

I agree to allow Coastal Family Health Center to contact me reguarding my private health information, evaluation and treatment.
Name of Individual Giving Authorization:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Relationship if other than patient:
Signature of Individual Giving Authorization:*

Clear
Date:*

MonthDayYear
Date
Witness:

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Authorization for Diagnosis and Treatment

The individual consents to medical, dental, behavioral/mental health, or optical examinations, treatments, and procedures during office visits at Coastal Family Health Center (CFHC), as deemed necessary by the attending physician, nurse practitioner, dentist, optometrist, or psychiatrist.

Notice of Privacy Practices

I acknowledge that I have reviewed and agree with CFHC’s Notice of Privacy Practices. I may obtain a copy of the Notice of Privacy Practices upon request.

Patients’ Bill of Rights and Responsibilities

I acknowledge that I have reviewed and agree with CFHC’s Patients’ Bill of Rights and Responsibilities. I may obtain a copy of the Patients’ Bill of Rights and Responsibilities upon request.

Photography

I hereby consent to have a photograph made of me or my child (or the person for whom I am a legal guardian) to be stored in my medical record, for the 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 care I receive at CFHC.

Late and No-Show Policy

I acknowledge that I have reviewed and agree with CFHC’s Late/No-Show policy. I may obtain a copy of the Late/No Show policy upon request.

Financial Agreement

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

For Patient with No Insurance:

The applicant agrees to apply for any Sliding Fee Discount as recommended by CFHC staff and understands that failure to provide proof of income and complete the process will result in being responsible for 100% of the charges. The applicant agrees to pay all charges for which the applicant is responsible at the time services are rendered or make payment arrangements with CFHC. CFHC reserves the right to limit services if payment is not made. CFHC may use a third-party vendor to collect undisclosed insurance, which will be applied before any discounts or adjustments are made to the account.

For Patient with Insurance:

CFHC will bill insurance, and the patient must show current insurance information, notify CFHC of coverage changes, pay co-payment and deductible, and contact insurance for uncovered services. Patients may request not to bill insurance for a specific visit at CFHC, agreeing to pay 100% of all charges.

I agree that I have read and understand the above consent and will accept its terms.
Signature of Patient/Parent/Guardian:*

Clear
Date:*

MonthDayYear
Date
Signature of Staff Witness:

Clear
Date:

MonthDayYear
Date
NOTICE OF PRIVACY PRACTICES (Short form)

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.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will elaborate on the meaning and provide more specific examples, if you request. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. We must obtain your authorization before the use and disclosure of any psychotherapy notes, uses and disclosures of (PHI (PHI) for marketing purposes, and disclosure that constitute a sale of PHI. Uses and disclosures not described in this Notice of Privacy Practices will be made only with authorization from the individual.
For Payment.
We may use and disclose medical information about you so that the treatment and services you receive at CFHC may be billed to and payment may be collected from you, an insurance company or a third party. For example: we may disclose your record to an insurance company, so that we can get paid for treating you.
For Treatment.
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at CFHC or the hospital. For example, we may disclose medical information about you to people outside CFHC who may be involved in your medical care, such as family members, clergy or other persons that are part of your care.
For Health Care Operations.
We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run CFHC and ensure that all of our patients receive quality care. We may also disclose information to doctors, nurses, technicians, medical students, and other Center personnel for review and learning purposes. For example, we may review your record to assist our quality improvement efforts.
WHO WILL FOLLOW THIS NOTICE.
This notice describes our Center's policies and procedures and that of any health care professional authorized to enter information into your medical chart, any member of a volunteer group which we allow to help you, as well as all employees, staff and other Center personnel.
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. The 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 the notice that is 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.

NOTICE OF INDIVIDUAL RIGHTS

You have the following rights regarding medical information we maintain about you:

Right to a Paper Copy of this Notice.
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.
Right to Inspect and Copy.
You have the right to inspect and copy medical information that may be used to
make decisions about your care. We may deny your request to inspect and copy in certain very limited circumstances.
Right to Amend.
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by, or for, Coastal Family Health Center. To request an amendment, your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your
request. We may deny your request for an amendment.
Right to Request Restrictions.
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide
you emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer.
Right to Request Removal from Fundraising Communications.
You have the right to opt out of receiving fundraising communications from Coastal Family Health Center.
Right to Restrict Disclosures to Health Plan.
You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full.
Right to Request Confidential Communications.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. You must make your request in writing and you must specify how or where you wish to be contacted.
Right to an Accounting of Disclosures.
You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer.
CHANGES TO THIS NOTICE.
We reserve the right to change this notice. We will post a copy of the current
notice in CFHC’s waiting room.
COMPLAINTS.
If you believe your privacy rights have been violated, you may file a complaint with CFHC or with the Secretary of the Department of Health and Human Services. To file a complaint with Coastal Family Health Center, contact our Privacy Officer at 228-374-2494, 1046 Division St. Biloxi, MS 39530. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to use will be made only with your written authorization. If you
provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.

If you have any questions about this notice or would like to receive a more detailed explanation, please contact our Privacy Officer.
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