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 (PDF)
• Pediatric Patient Information (PDF) 
• Pediatric Medical History Form (PDF)
• Pediatric Stimulant Medication Agreement (PDF)

Request for Medical Records

Click to Request Your Medical Records Online

Coastal offers an online patient record request for the following individuals to request patient records:

• Patients requesting their own records
• Parents of minor patients requesting records
• Caregivers acting on behalf of a patient (i.e. Power of Attorney)

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

Printable Version - Medical Record Request Form (PDF)