Forms for Current Clients

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

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

 

Safety & Wellness Plan Acknowledgement Form

 

Consent to Record Treatment Sessions

 

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

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

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