Patient Forms

The document below are provided in a printer friendly PDF format. A PDF viewer such as Adobe Reader is required to view the documents and can be downloaded free by clicking on the image at the bottom of the page.

New patients, Please print out the New Patient Packet, complete the forms, and bring them with you to your first appointment.

  • New Patient Packet - Collection of forms needed for new patients

  • Consent to treat

  • Notice of Privacy Practices

  • Medication Authorization

  • Release of Billing Information

  • Assignment of Benefits


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The Alaska Medicare Clinic, Inc is a 501(c)(3) non-profit outpatient health care clinic developed to meet the primary care needs of the Medicare-eligible population in Anchorage.

We are now accepting patients, so schedule your appointment today!

Phone: (907) 433-5100

Fax: (907) 433-5110

11260 Old Seward Highway #107
Anchorage, AK 99515 [Map]