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.
All Alliance patients are required to renew their eligibility annually. The following documentation is required:
You must complete ALL of the following in 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 (one of the below)
- Tax Form 1040 OR
- Tax Form 4506-T - Download: English PDF
Proof of income source B (one of the 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 contact information stating weekly or monthly income.
OPTION 3: If income is direct deposited, a bank statement showing a month's worth of direct deposits
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
Please also review: