Form must be notarized if not witnessed by provider, clinic or hospital.
Please complete this form online then print a copy, have it notarized, and submit it to our office at: 4000 Old Seward Highway, Suite 203, Anchorage AK 99503
STATE OF _______________
The foregoing signature was acknowledged before me this ______ day of ______________ as an authorized, free and voluntary act. IN WITNESS WHEREOF, I have hereunto set my hand and seal.
Notary Public for: ________________________
My Commission Expires: _________________