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.