Direct Billing Acknowledgement & Agreement *

I acknowledge that North Coast Wellness currently only sees patients located in Michigan and currently is only able to accept Priority Health Insurance products. I would like to move forward with being contacted and agree to pay out of pocket for services rendered.

Name *

First Name

Last Name

Date of Birth *

Required to create a patient portal account for scheduling

MM

DD

YYYY

Phone *

(###)

###

####

Inquiring about

Services

Scheduling