As your physician, I am committed to providing you with the best possible medical care 2026

1. Click 'Get Form' to open it in the editor.
2. Begin by reviewing the Financial Responsibility section. Acknowledge that you are responsible for all charges incurred for services rendered.
3. Fill in your payment method under Payment for Services. Choose from cash, personal checks, MasterCard, or Visa.
4. Complete the HMO/PPO Insurance Coverage section by providing a copy of your current insurance card and any necessary referrals.
5. If applicable, sign the Medicare section authorizing payment directly to Coastal Spine & Pain Center and acknowledging your financial responsibilities.
6. Initial next to the No Show Policy to confirm your understanding of potential charges for missed appointments.
7. Sign and date at the bottom of the form, ensuring all required fields are completed accurately.

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