Coastal Medical Patient Forms

Please see below for several forms that may be helpful to you as a Coastal Medical patient.

• New Patient Forms Packet - Adult and Family (PDF)
• Notice of Privacy Practices - HIPAA (PDF)
• Advance Care Planning:
  • About Advance Directives (PDF)  
  • RI MOLST Form (English PDF)
  • RI MOLST Form (Spanish PDF)
  • Connecticut website  
  • Massachusetts website
  • Rhode Island website 
• Permission to Discuss (PDF)
• Request for Medical Records - New Patients (PDF)
• Request for Medical Records - from Coastal Medical (PDF)
• Pediatric Patient Information (PDF) 
• Pediatric Medical History Form (PDF)
• Pediatric Stimulant Medication Agreement (PDF)

Request for Medical Records

Requests for patient's medical records will be billed to the patient according to state regulations.

Online Forms for Requesting a copy of Medical Records

• Patient Online Access Form - for individual patients or their legal guardians to request medical records.
• Third Party Request Portal - for healthcare providers, attorneys or those requesting the medical records of someone other than themselves (and who are not the legal guardian).

Print Version 

• Request for Medical Records - New Patients (PDF)
• Request for Medical Records - from Coastal Medical (PDF)