Get Coastal Health &amp

Filling out the Coastal Health & Wellness application for discounted services is a straightforward process designed to assist users in receiving the healthcare services they need. This guide provides clear, step-by-step instructions to help you complete the application online.

Follow the steps to successfully submit your application for discounted services.

1. Click the ‘Get Form’ button to obtain the application for discounted services and open it for editing.
2. Begin by entering your personal information in the designated fields, including your name, home telephone number, and billing address. Ensure that the information is entered clearly and accurately.
3. Indicate whether you have used another name by selecting 'Yes' or 'No'. If applicable, provide your previous last name or nickname.
4. Choose your marital status from the provided options: married, single, divorced, widowed, or legally separated.
5. List everyone who lives in your household, including their name and relationship to you. Be sure to include all relevant household members.
6. For each household member planning to become a patient, provide their date of birth, sex, race, and ethnicity using the provided categories.
7. Detail your household’s income for each person working or receiving money. Include the name of the employer or agency and the amount received, ensuring to specify how often the income is received.
8. If applicable, indicate whether anyone in your household has health insurance by listing relevant details, including the policyholder's name and the insurance provider.
9. Review the information you have entered, ensuring all answers are complete and accurate. Make sure to verify your understanding of the conditions described in the application.
10. Sign and date the application at the bottom to confirm the truthfulness of the information provided. After signing, save your changes or download the completed form.
11. Once you have saved the application, you can choose to submit it online, print it for mailing, or share it as needed.

Start your application for discounted services by filling out the Coastal Health & Wellness form online today.