Client Forms

We use a HIPAA-compliant vendor to securely deliver client forms submitted through our website.

 

FORMS NEEDED FOR NEW CLIENTS

Please click on the buttons below to fill out and submit forms on-line.

Client Contact Info & Consent Form

 

Please read the following policies, and then click the button to sign the acknowledgement form:

Joint Notice of Privacy Practices

Consumer Rights & Responsibilities

Consumer Grievance Process

Appointment Policy & Agreement

Consumer Safety Guidelines & Procedures

Acknowledgement of Policies

 

Client Financial Policies

 

If you prefer and if you have access to a printer, you may download, print and complete the entire intake packet here and use the button below to upload the forms to us.

File Upload Form

 

FORMS NEEDED FOR TELE-HEALTH

Please click on the buttons below to fill out and submit forms on-line.

Consent for Telehealth Form

 

Consent for Electronic Communication Form

 

Click here for tips on using Zoom

 

These forms can not be submitted on-line. They are provided for reference as you discuss them with your provider:

Client Status Review Form

Alaska Screening Tool

 

ADDITIONAL CLIENT FORMS / INFORMATION

Consent for Services by a Student Intern

 

Treatment Plan Acknowledgement Form

 

Consent to Record Treatment Sessions

 

Homeless Management Information System Consumer Privacy Notice

Consumer Grievance Form   NOTICE:  The Consumer Grievance Form cannot be submitted online.  The form can be hand delivered to any ACMHS location, faxed to 907-375-3115, or mailed to:

ACMHS
Attention: Privacy Officer
4020 Folker Street
Anchorage, AK 99508

Release of Information Form  NOTICE: The Release of Health Information form cannot be submitted on-line or by e-mail.  The form can be hand delivered to any ACMHS location, faxed to 907-375-3115, or mailed to:

ACMHS
Attention: Clinical Records
4020 Folker Street
Anchorage, AK 99508

Request for Access to or Copies of Records If you are a client and are requesting a copy of your own records, you will need to fill out both the ROI and this Request for Access Form.

NOTICE: The Release for Access form cannot be submitted on-line or by e-mail.  The form can be hand delivered to any ACMHS location, faxed to 907-375-3115, or mailed to:

ACMHS
Attention: Clinical Records
4020 Folker Street
Anchorage, AK 99508