Forms

The mission of Capstone Family Medicine is to provide Alaska with the best, most comprehensive, quality family healthcare.

Capstone Clinic Forms

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.

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.

Medicare Annual Wellness Visit Forms

Medicare Annual Wellness Visit

At Capstone Clinic, we prioritize your health and well-being. As part of our commitment to providing comprehensive care, we invite you to schedule your Medicare Annual Wellness Visit.

What is a Medicare Annual Wellness Visit (AWV)?
A Medicare Annual Wellness Visit is a yearly appointment designed to help you prevent illness and maintain your overall health. During this visit, our healthcare professionals will:

1. Review Your Health History: We’ll discuss your medical history and any changes in your health since your last visit.
2. Health Risk Assessment: We’ll assess your current health and identify any potential risks or areas for improvement.
3. Personalized Prevention Plan: Together, we’ll create a personalized plan focusing on preventive care, screenings, and vaccinations tailored to your individual needs.
4. Medication Review: We’ll review your current medications to ensure they're still appropriate and effective.
5. Discussion of Advance Directives: We’ll provide information and guidance on advance care planning and help you make informed decisions about your healthcare preferences.

Scheduling your Medicare Annual Wellness Visit is easy! Call our office at 1-907-357-9590 to book your appointment. Our friendly staff is ready to assist you in selecting a convenient time for your visit.

Investing in your health today can lead to a healthier tomorrow. We look forward to partnering with you on your wellness journey.

Sports Physical

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

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:

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

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.

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

Late Arrivals
Patients arriving ten or more minutes late for their scheduled appointment will be rescheduled to the next available appointment time.

No Show/Missed Appointments
Capstone requires a 24-hour notice for appointment cancellations or reschedules. After two missed/no show appointments, an account may be reviewed for discharge from the practice. New patients will not be allowed to reschedule their appointment if they no-show or cancel within 24-hours.

After Hours
We take pride in being available for urgent health care issues. Therefore, our physicians can be reached after office hours if necessary. Please call our office number and enter option #3 to reach the physician directly. 

Prescription Refills
Please bring your pill bottles to appointments and review dosing with your doctor. We ask that you request any needed refills at your visit. If you forget something, please allow us 48-72 hours for phone refills. 

Test Results
Physicians may order tests to help diagnose and treat your medical condition. You will be notified of any abnormal test result within twenty-four (24) hours of the provider reviewing the report. You will be notified of normal test results within two (2) weeks of the provider reviewing the report. If you do not hear from your provider please call and inquire. Your provider may not have received your results. Please note you may receive a separate bill from Quest Laboratory for processing the lab specimen. It is your responsibility to know if your insurance has another preferred lab.

Health Plan Participation
Capstone Family Medicine is a preferred provider with Blue Cross, Aetna, Cigna, United HealthCare and Moda, as well as participating provider with Medicaid, Tricare and Medicare. We do not accept ANS.

Financial Responsibility
Capstone Family Medicine will bill your insurance as a courtesy. However, you are responsible for your portion of your bill(for example, co-pays, deductibles, services not covered by your health plan, etc.) at the time of your visit. Remember that the contract with your insurance company is between you and them and it is your responsibility to know your policy. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payment, covered charges, secondary insurance, usual and customary charges, etc., other than to supply factual information as necessary.

Hospital Privileges
Our physicians have privileges at Mat-Su Regional Medical Center. If you are seen at this facility, please note you will get a separate bill from the hospital.

Capstone Clinic

From Monday to Friday, our team is available to assist you during the hours of 8:00 AM to 5:00 PM. Should you prefer an alternative method, you're welcome to use our contact form or get in touch via phone or email from our Locations Page. Our team members are here and ready to help.

Telephone number: 907-357-9560

Email: info@capstoneclinic.com