PATIENT INFORMATION & FORMS
You have the option for Online Submission or PDF for select forms. For online submissions, any missing/incomplete/inaccurate information will require resubmission or in-person review.
You can print the PDF and provide handwritten responses. Please bring the form to your visit, mail or fax to us.
*Online form submissions are currently unavailable, we apologize for the inconvenience.
If you are a new patient, we are unable to process Medicaid Travel per Medicaid. It is your responsibility to contact your primary care provider to arrange Medicaid Travel.
Medicaid will provide travel once per month per specialty. If you have multiple appointments with us, notify us immediately.
Allow adequate time for processing. For cab vouchers, provide at minimum one week's notice; for hotel and/or air travel, provide two weeks' notice. Once travel is approved, it is patient responsibility to book airline ticket(s) and/or hotel room(s).
Notify the clinic immediately of any cancellations or rescheduling of your appointment(s).
We cannot guarantee that Medicaid will provide travel even if requested within the above parameters. If Medicaid denies travel, it is the patient's responsibility for adequate transportation to and from appointment(s).
It is advised that you initiate and/or confirm Medicaid Travel arrangements with our office at time of appointment scheduling.
Travel vouchers will not be mailed unless you require air travel to Anchorage.