Please click on the links below to download forms.

Forms are now available online to make visits faster and more convenient for you! When you come to your visit prepared, you will be able to make the most of the time you have with your Provider.

forms

Anchorage School District

(forms that require a healthcare provider signature - PLEASE ALLOW 24-48 hours for requests to be completed)

ASD Health Exam Sports Physical Form - EASY ONLINE SIGNATURE (sign online - mobile app will require a free app download. please note that this will email your form which is not secure)

ASD Health Exam Sports Physical Form - DOWNLOAD, COMPLETE, PRINT, SEND (print and send either securely through our site or by email which is not secure)

ASD School Entry Physical Form - EASY ONLINE SIGNATURE (sign online - mobile app will require a free app download. please note that this will email your form which is not secure)

ASD School Entry Physical Form - DOWNLOAD, COMPLETE, PRINT, SEND (print and send either securely through our site or by email which is not secure)

ASD Asthma Action Plan

ASD Allergy/Anaphylaxis Plan


policies.jpg

Please review the following policies

Below you will find our policies on prescription renewal, billing and payment, and privacy. If you have questions, we will be happy to assist you! Just give us a call at 777-1800.

Prescription Renewal: Many prescriptions can be renewed by phone. However, there are times when we ask that you make an appointment before the prescription can be refilled. This request is to ensure that your child is receiving the best possible medical care.

For prescription renewal please call us during office hours. Except in emergencies, for your child’s protection, we do not refill medication after hours when the medical records are not available. ACP can typically accommodate prescription requests within 24-48 hours, but we may require72 hours to complete. We ask our patients to plan accordingly.

>>>To renew a prescription through patient portal, click here.

Immunization Refusal: It is the policy of ACP to document the health care provider’s discussion with parents about the serious risks of what could happen to an unimmunized or underimmunized child. ACP will provide parents with the appropriate VIS for each vaccine at each immunization visit and answer their questions. For parents who refuse one or more recommended immunizations, ACP will document the conversation and the provision of the VIS(s), have a parent sign the Refusal to Vaccinate form, and keep the form in the patient’s medical record. ACP will revisit the immunization discussion at each subsequent appointment and carefully document the discussion, including the benefits to each immunization and the risk of not being age-appropriately immunized. For unimmunized or partially immunized children, ACP will flag chart to be reminded to revisit the immunization discussion, as well as to alert the provider about missed immunizations when considering the evaluation of future illness, especially young children with fevers of unknown origin.

Privacy: Medical information shared with us is confidential. It is shared with other health care providers, hospitals, schools, and/or insurance companies only with your written authorization. (Some diseases and injuries are required by law to be reported to State Health Agencies.)

We respect your teenager’s need for privacy. As your child reaches puberty we may ask that parents leave the exam room briefly. This allows us to discuss sensitive issues and examine your teenager without causing undue embarrassment. Teenagers appreciate this courtesy.

>>>Please view our Notice of Privacy Practices.

Billing: Payment is expected at the time of the visit. We accept Visa, MasterCard, American Express as well as cash and personal checks.

We are a preferred provider for Aetna, Blue Cross/Premera, Cigna, MultiPlan and Tricare insurance companies. If your child’s visit is covered by health insurance we will bill all insurances (primary, secondary, tertiary) after a copy of your insurance card has been added to our system. However, if the primary insurance has paid the claim in full it will be the guarantor’s responsibility to submit the claim to secondary and/or tertiary insurances. Legal guardians remain responsible for any copayments, coinsurance, and deductibles at the time of service.

Medicaid patients are required to present a current card or sticker at the time of service.

If you have questions about your child’s medical bill or have financial difficulty that may require a payment schedule, please let us know.

>>>Please view our Billing Policies.