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 NoticeFORMS NEEDED FOR TELE-HEALTH
Please click on the buttons below to fill out and submit forms on-line.
Consent for Telehealth FormConsent for Electronic Communication Form
Click here for tips on using Zoom
ADDITIONAL CLIENT FORMS / INFORMATION
Update Client Contact InformationEmergency 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
Sample Completed Release of Information
You may also download the Release of Information Form and fax it to 907-375-3115, deliver to any Alaska Behavioral Health location, or mail it to:
Alaska Behavioral Health
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 Alaska Behavioral Health location, faxed to 907-375-3115, or mailed to:
Alaska Behavioral Health
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 Alaska Behavioral Health location, faxed to 907-375-3115, or mailed to:
Alaska Behavioral Health
Attention: Clinical Records
4020 Folker Street
Anchorage, AK 99508