Forms

New patient forms, COVID test forms and more

COVID Test Request Form

Capstone will perform collections first thing in the morning for pre op to avoid exposing these asymptomatic persons to potentially infectious patients.

Capstone will collect Monday through Friday 0730 to 0800 and from 1000 to 1100 Saturday and Sunday.

The providers will need to fill out the form for each requested pre op screen.  They will populate the form and fill in the ‘expected collection date’ indicating when the patient should arrive.  Surgery Centers should advise patients exactly when they want them to arrive for testing.  There is a ‘click to submit’ button at the bottom of the form which will send it to the lab in-box.

Lab will print these forms and register the patient on the scheduled date in the EHR (we will get admin support to assist with this if needed).

Patients will need to be emailed the docusign consent for release form by admin staff at Capstone.

On the collection date, the patients will be pulled up and collected as usual.

These patients will be documented in the EHR.

If we have a patient that was expected to arrive for collection and did not show, we should notify the referring surgery center so they can contact the patient for rescheduling.  This is an administrative burden but must be accomplished to allow surgical centers to adjust their schedules in near real time.

When results are in, these will be sent to the respective surgery center ASAP.

FOR SURGERY CENTER LEADERS:

We will collect as noted above.  We intend to have a currier transport labs and have specimens to the State lab in Anchorage by 10am.

The State Lab receives samples daily but does not run tests every day.  On Friday, they send labs to Fairbanks for processing which may delay results (if you plan cases on Sunday).

On Sunday, the State lab does not process samples at all.  They hold them until Monday.  This means, Tuesday cases will very likely not have a result in the required 48 hour window.  We are advising clinics to be very careful about Tuesday cases and any cases before 9am or so until we can confirm Turn Around Time for these samples.

 

 

Patient COVID Test Request Form

 

Pre-registered Employee COVID Test Request Form

 

New Patient Paperwork

All new patients must fill out the New Patient Paperwork before being seen. Patients 17 and under will need to have these forms filled out by a parent or guardian.

 

New Patient Paperwork

 

Minor Consent to Treat

Complete this form to authorize your minor child (age 17 and under) to be seen with another adult present or by his/her self. This form must be completed in the presence of a Capstone Family Medicine employee unless it is notarized.

 

Minor Consent to Treat

Sports Physical

Complete this form if your minor child is being seen for a sports physical.

 

Sports Physical Paperwork

Well Child Questionaires

Well Child Check Questionaires: Share your childs ASQ results securely and conveniently with your childs medical provider via a confidential online portal. Ages and Stages Questionnaires (ASQs) are a key part of your childs standard well child exams from ages 2 months through 5 years. We encourage parents to complete and submit these age-appropriate developmental screening questionnaires through the secure link below prior to the child’s exam:

 

Palmer Online Screening
Wasilla Online Screening     Eagle River Online Screening 

Medical Records

Your request will be processed in the order in which it was received. The records can be mailed, faxed, or picked up from the clinic; please mark your preference on the form.

Capstone Family Medicine
Attn: Medical Records
3122 E. Meridian Park Loop
Wasilla, AK 99654
PH: 907-357-9590
Fax: 907-357-9544
E-mail: medicalrecords@capstoneclinic.com

Release of Information

 

Copies of Medical Records

Due to the high volume and time-consuming nature of requests, Capstone Family Medicine has implemented the charges below for Medical Records.

PAPER COPIES ELECTRONIC FORMAT

1-25 pages: FREE Disc: $15.00
26-50 pages: $20.00
51-75 pages: $25.00
76-100 pages: $30.00
100+ pages: $40.00

*Charges will not exceed $40.00 and payment will be due prior to records being released.

The offices of Capstone Family Medicine will not charge a fee for processing requests for releases to medical insurance companies or for Workers’ Compensation.

If you are discharged from a Capstone Family Medicine clinic, your records may be provided to you on a one-time basis at no cost.

Alaska Department of Health and Social Services Links

Advance Health Care Directive (Living Will)

You have the right to give instructions about your own health care to the extent allowed by law. You also have the right to name someone else to make health care decisions for you to the extent allowed by law. This form allows you to do either or both of these things. It also lets you express your wishes regarding the designation of your health care provider.

Alaska Comfort One Program

Some individuals who are terminally ill do not wish to have life-saving measures, such as cardiopulmonary resuscitation (CPR), performed on them when their breathing and heartbeat stop. The Comfort One Program was established in 1996 to help health care providers identify terminally-ill people who have expressed these wishes.

WASILLA

3122 E Meridian Park Lp
Wasilla, AK 99654
Phone: 907-357-9590
Fax: 907-357-9593

ANCHORAGE

4361 Boniface Pkwy
Anchorage, AK 99504
Phone: 907-333-2133
Fax: 907-333-2139

EAGLE RIVER

17025 Snowmobile Ln
Eagle River, AK 99577
Phone: 907-694-9553
Fax: 907-694-9585

KENAI

10543 Kenai Spur Hwy
Kenai, AK 99611
Phone: (907) 395-0463
Fax: (907) 395-0483

PALMER

12039 E Maplesprings Way, Suite A,
Palmer, AK 99645

Phone: 907-745-9088
Fax: 907-745-9099

IDEAL PROTEIN

Please call our office
or e-mail Ashley
Phone: 907-357-9590
Learn More

URGENT CARE

3066 E Meridian Park Lp
Wasilla, AK 99654
Phone: 907-357-9560
Fax: 907-357-9596

KENAI

10543 Kenai Spur Hwy
Kenai, AK 99611
Phone: (907) 395-0463
Fax: (907) 395-0483

WASILLA

3122 E Meridian Park Lp
Wasilla, AK 99654
Phone: 907-357-9590
Fax: 907-357-9593

ANCHORAGE

4361 Boniface Pkwy
Anchorage, AK 99504
Phone: 907-333-2133
Fax: 907-333-2139

EAGLE RIVER

17025 Snowmobile Ln
Eagle River, AK 99577
Phone: 907-694-9553
Fax: 907-694-9585

PALMER

12039 E Maplesprings Way, Suite A,
Palmer, AK 99645

Phone: 907-745-9088
Fax: 907-745-9099

IDEAL PROTEIN

Please call our office
or e-mail Ashley
Phone: 907-357-9590
Learn More

EXPRESS

320 W. 5th Ave Ste 152
Anchorage, AK 99501
Phone: 907-929-1340
Fax: 907-333-2139

URGENT CARE

3066 E Meridian Park Lp
Wasilla, AK 99654
Phone: 907-357-9560
Fax: 907-357-9596

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