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.  

Annual Renewal:

All Alliance patients are required to renew their eligibility annually.  The following documentation is required:

Patient Application – Download:  English Application or Spanish Application:

You must complete ALL of the following in numbers 1-9 and submit to Alliance's Patient Services: 

  1. COPY of a current Government issued photo ID (Driver’s license, Green Card, VISA, etc.).
  2. COPY of proof of Wake County residency (utility bill, telephone bill or property tax bill).
  3. COMPLETED Patient Information Form (Patient Application)
  4. COMPLETED Health History Form (Patient Application)
  5. SIGNED Patient Responsibility and Accountability Contract (Patient Application)
  6. SIGNED Medical Release Form (Patient Application)
  7. SIGNED Limited Power of Attorney (Patient Application)
  8. Proof of income source A (one of the below) 
    1. Tax Form 1040 OR
    2. Tax Form 4506-T - Download: English PDF
  9. Proof of income source B (one of the below)

    1. OPTION 1:  One month of current consecutive pay stubs from any household member

    2. OPTION 2:  If a patient does not receive pay stubs, a notarized letter from their employer with contact information stating weekly or monthly income.

    3. OPTION 3:  If income is direct deposited, a bank statement showing a month's worth of direct deposits

    4. OPTION 4:  If patient is self-employed, six (6) months worth of bank statements showing income deposits which may be averaged to compute income.

Patient Responsibility and Accountability

All Alliance patients are required to sign a Patient Responsibility & Accountability Contract.  Download the contract to review the terms of your agreement with Alliance.     English PDF    Spanish PDF

Please also review: