Forms for Current Clients

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

Client Consent Form

If you have Medicare insurance, please complete the required Advanced Beneficiary Notice.

Advanced Beneficiary Notice

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

ADDITIONAL CLIENT FORMS / INFORMATION

Update Client Contact Information

 

Emergency Contact Release of Information

 

Consent for Services by a Student Intern

 

Treatment Plan Acknowledgement Form

 

Safety & Wellness Plan Acknowledgement Form

 

Consent to Record Treatment Sessions

 

Parenting with Love & Limits Data Collection Consent Form

 

Release of Information Form

 

You may also download the Release of Information Form and fax it to 907-375-3115, deliver to any ACMHS location, or mail it to:

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

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

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