Patient Eligibility Requirements:
18 Years or older
- Resident of Wake County
- No health insurance
- No Medicaid
- Employed or live with a family member who is employed by Wake County
How to Become a Patient
If you would like to become a patient at Alliance and meet the eligibility requirements listed above, you will need to complete a Patient Application and deliver it to alliance before being scheduled for an appointment. This information will be reviewed and you will be contacted to schedule and appointment.
In order to apply to become an Alliance patient, you must complete ALL of the following numbers 1-9 and submit to Alliance's Patient Services:
COPY of a current Government issued photo ID (Driver's license, Green Card, Visa, etc.).
- COPY of proof of Wake County residency (utility bill, telephone bill, or property tax bill).
- COMPLETED Patient Information Form (Patient Application)
- COMPLETED Health History Form (Patient Application)
- SIGNED Patient Responsibility and Accountability Contract (Patient Application)
- SIGNED Medical Release Form (Patient Application)
- SIGNED Limited Power of Attorney (Patient Application)
- Proof of income source A (of of below)
- Tax Form 1040 OR
- Tax From 4506-T - Download: English PDF
- Proof of income B (one of below)
- Option 1: One month of current consecutive pay stubs from any household member
- Option 2: If a patient does not receive pay stubs, a notarized letter from their employer with contract information stating weekly or monthly income
- Option 3: If income is direct deposited, a bank statement showing a month's wort of direct deposit
- Option 4: If patient is self-employed, six (6) months worth of bank statements showing deposits which may be averaged to compute income.
How to make an appointment:
All appointments in our primary care clinic must be scheduled.
If you are an established patient at Alliance and want to make an appointment, please call (919) 250-3320 and follow the prompts.
If you are a new patient and have delivered your completed patient package to Alliance, you will be contacted by our Patient Services upon review and approval to set up an appointment.
Requirements for first appointments:
- Arrive 15 minutes before scheduled appointment
- Must bring all current medications
- Must bring co-pay. *Payment is expected at time of service. The average co-pay is $25.00. We accept cash, personal checks, and Mastercard & Visa debit cards.*
- You will receive your Alliance card at your first appointment, which you must bring with you to all future appointments.
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