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Patient Enrollment Forms:

Please print out and complete at your convenience. You can mail the completed packet to the office (2150 Main St, Ste. 3, Cambria, CA, 93428), email (info@coastalpinesmedical.com), or call the office to schedule a time to drop off (805-927-1673). Thank you. We look forward to connecting with you soon!

Copy of 0- Cover Sheet.jpg
Copy of 1- Membership Benefits_Page_1.jpg
Copy of 2- Fee Schedule.jpg
Copy of 3- Membership Agreement_Page_1.jpg
Copy of 4- Financial Agreement_Page_1.jpg
Copy of 5- Payment Information.jpg
Copy of 6-Patient Medical Intake_Page_1.jpg
Copy of 7-Patient expectations_Page_1.jpg
Copy of 8a- Patient Rights _ Responsibilities_Page_1.jpg
Copy of 8b- Pt R_R.jpg
Copy of 10-Medical Release Form.jpg
Copy of 9a-Notice of Privacy Practices_Page_1.jpg
Copy of 9b- Privacy Practices Attestation.jpg
Copy of 11- Release of med info to family.jpg
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