Patient Eligibility Requirements
- 18 years or older
- Resident of Wake County
- No health insurance
- No Medicaid or Medicare
- Employed or live with a family member who is employed by Wake County
How to Become a Patient
Step 1: If you meet the requirements listed above, download and complete a Patient Application:
Note: Your Patient Application must be completed in full, including:
- Patient Information Form
- Health History Form
- Signed Patient Responsibility and Accountability Contract
- Signed Medical Release Form
- Signed Limited Power of Attorney
Step 2: Gather these additional documents:
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)
- Proof of income source A (one of below)
- 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
Step 3: Bring your completed Patient Application and additional documents to Alliance Medical Ministry.
- The Patient Services Team will review your Patient Application and documents.
- The Patient Services Team will contact you to:
- Request missing information or
- Schedule your first appointment
At your first appointment:
- Arrive 15 minutes before scheduled appointment
- Bring all current medications
- Bring co-pay:
- Payment expected at time of service
- Average co-pay is $25
- Cash, personal checks, Mastercard & Visa accepted
- You will receive your Alliance Patient card, which you must bring with you to all future appointments.
You're a patient now!
- All patients are required to sign a Patient Responsibility and Accountability Contract.