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Alaska Informed Consent for Abortion

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Alaska Informed Consent for Abortion Website
Resources List
Applicant Request Form

Directions:

1. Please provide your contact information in the spaces below. Please note that in order for department staff to verify the accuracy of the information you provide, you must include a current telephone number below. (Please type or write legibly.)

Your name - please specify:

list my name as contact for organization or facility;

do not list my name; list organization name only

Contact Information
Organization/Firm Name
Work Address #1
Work Address #2
City, State, Zip code
Phone number
Fax number
Website and/or email address

2. Select ONE category (A-H) from the list below under which you would like your agency, services, clinic or facility to be listed on this website (select the category that best describes your facility or services).

3. Under the category you select, please check the box(es) that most accurately describe(s) the services you/your facility provide, where applicable. Check all that apply.

4. Please use selection “H” below to submit telephone hotline numbers and internet resource links for inclusion on this website; please include a brief description of the resource(s) you list.

5. Use the space at the bottom of the application to add any written comments or clarification. Department staff will try to incorporate additional information you provide; however, please note that additional information must be brief and restricted to clarifying the description of services you provide.

A. Hospital, Community Health Center, or Rural Health Clinic

OR

B. Private health care practitioner licensed to practice in the state of Alaska:

MD/DO Nurse Practitioner/Nurse Midwife Physician’s Assistant

AND your/your facility provide(s) the following type(s) of services(s) to pregnant women (check all that apply):

clinical OB/GYN services, including prenatal care, designed to assist a woman in carrying her pregnancy to term, provided by an MD, PA, NP or Nurse Midwife licensed to practice in Alaska;

adoption services, designed to assist a woman with a legal adoption after giving birth;

abortion services; clinical services designed to assist a woman who chooses to terminate her pregnancy, provided by a licensed clinician legally authorized to perform this service in Alaska;

pre- and/or post-abortion counseling by:

a licensed or certified social worker or counselor

a trained (unlicensed/ uncertified) counselor, paid or volunteer

clinical family planning services, including counseling for appropriate family planning methods and provision of contraceptives;

referral services designed to assist a pregnant woman seeking further information, counseling or support for any of her pregnancy options, offered by qualified professionals or facilities.

C. Social Worker licensed to practice in Alaska, who offers pregnancy-related counseling, support, and referral services to pregnant women.

D. Faith-based agency or provider that offers pregnancy-related counseling, support, and referral services to pregnant women by:

a licensed or certified social worker or counselor

a trained (unlicensed/ uncertified) counselor, paid or volunteer

E. Adoption Agency, licensed by the State of Alaska, offering services designed to assist a pregnant woman with the legal adoption process after giving birth.

F. Attorney, licensed to practice in Alaska, who assists pregnant women with child placement/adoption services (i.e., services designed to assist a woman with the legal adoption process after giving birth) as a part of your practice in Family Law.

G. Other Agency, Service, Clinic, or Facility that offers Pregnancy-related counseling, support, and/or Clinical Services but does not fit into categories A – F above.

For “Other”, please describe briefly the services you provide to pregnant women:

H. Telephone Information Lines or Internet Resources Links:

Other comments:

The State of Alaska reviews and updates the information on the Informed Consent for Abortion website on an annual basis. Your application will be reviewed by department staff at that time and you will be notified in writing when your request is processed. In order for department staff to verify the accuracy of the information you provide, you must include a current telephone contact number on this application.

Please return this application (3 pages) directly to:

State of Alaska, DHSS,

Division of Public Health

ATTN: Kelly Keeter

3601 C Street, Suite 978

Anchorage, AK 99503

Thank you for your request.

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What the Alaska Informed Consent for Abortion Is and why it matters

The Alaska Informed Consent for Abortion is a written acknowledgement used in clinical settings to document that a patient received required information about abortion procedures, alternatives, risks, and follow-up care. It records the patient’s voluntary decision to proceed after counseling and verifies identity, date of discussion, and the clinician or counselor who provided the information. The form functions as a clinical and legal record: it supports informed decision-making, documents compliance with applicable state requirements, and becomes part of the patient’s medical record retained under applicable privacy and recordkeeping rules.

Why a clear, compliant informed-consent form matters

A complete, well-documented Alaska Informed Consent for Abortion protects patient autonomy, supports clinical quality, and creates an auditable medical record that meets HIPAA retention requirements and any applicable state rules.

Why a clear, compliant informed-consent form matters

Who typically completes or reviews this consent form

Clinics, health systems, reproductive health counselors, and authorized clinicians use the Alaska Informed Consent for Abortion to document patient counseling and consent before care.

  • Clinicians and Counselors — Physicians, advanced practice clinicians, or certified counselors who provide required information and confirm understanding.
  • Clinic Administrators — Staff who ensure the form is stored in the medical record and processed under privacy protocols.
  • Patients — The individual receiving the procedure; their signature documents voluntary consent and receipt of information.

Maintain role-based access and accurate signer attribution so clinical, legal, and audit requirements are met and the record is reproducible if needed.

Core elements to include in a professional consent form

A professional Alaska Informed Consent for Abortion should be concise, use plain language, capture identity and dates, summarize risks and alternatives, document counseling, and include a clear signature block for the patient and clinician.

Patient identity

Full legal name, date of birth, and a secondary identifier (medical record number or government ID) to ensure accurate matching to the medical chart and billing record.

Procedure details

Brief description of the planned procedure type, gestational age if applicable, and any facility-specific identifiers so the record references a defined clinical intervention.

Risks and benefits

Plain-language summary of common and serious risks, likely benefits, and expected recovery to support the patient's understanding and informed decision.

Alternatives

Document reasonable alternatives discussed (e.g., expectant management, adoption, continuation of pregnancy) and any referrals offered or declined by the patient.

Counseling record

Date/time of counseling, name and role of the counselor, and a short statement confirming that questions were answered and informed consent was obtained voluntarily.

Signature and dating

Patient signature and date, clinician signature and date, and witness or attestation lines when required by policy or law.

Essential data points and privacy notes to capture

Patient name: Full legal name
Date of birth: MM/DD/YYYY
Medical record number: Clinic-assigned ID
Counseling date: MM/DD/YYYY
Provider name: Clinician or counselor
Signature type: Wet or electronic

Step-by-step: completing the consent form at the point of care

Follow a consistent sequence to confirm identity, review information, document counseling, and capture signature to create a complete medical record.

  • 01
    Verify identity: Confirm patient identity with ID and chart match.
  • 02
    Provide counseling: Discuss risks, benefits, and alternatives.
  • 03
    Record details: Complete fields: dates, provider, procedure.
  • 04
    Obtain signature: Collect patient and clinician signatures.

Configuring a secure e-consent workflow

When using an electronic workflow, configure fields, signer order, and authentication to match clinical policy and legal requirements.

Field | Configuration Signer order | Patient first, provider second
Authentication method Email link or SMS code; consider stronger auth for remote signers
Required fields Make name, DOB, counseling date, and signature mandatory
Audit trail Enable IP, timestamp, and action logging
Document retention Store signed PDF in EHR with access controls

Where to file and how signed forms should flow

Define a consistent routing path so completed consent forms are captured in the medical record, accessible to authorized staff, and retained under privacy rules.

  • Patient copy: Provide a copy for the patient if requested
  • EHR upload: Attach signed PDF to the patient chart
  • Administrative review: Clinic admin confirms completeness
  • Legal hold: Flag records if litigation or audit expected

Technical and privacy requirements for e-signature platforms

Choose a platform that supports secure authentication, a tamper-evident audit trail, and appropriate compliance features for healthcare records.

  • Authentication options: Email, SMS code, or stronger
  • Audit trail: IP, timestamp, event log
  • HIPAA support: BAA available

Ensure vendor agreements include a BAA if records contain protected health information and verify encryption at rest and in transit to protect patient privacy.

Timing and any time-sensitive steps to track

Track counseling and signature dates carefully; time stamps show counseling preceded treatment and support compliance with clinical policy and any applicable statutes.

Counseling date recorded:

Must precede procedure date when required by policy

Signature date:

Date the patient signed the form

Provider attestation date:

Date the clinician confirms counseling and consent

Record upload timeline:

Attach to EHR within clinic-defined timeframe

Audit retention start:

Retention measured from counseling or creation date

Common legal and operational risks of incomplete consent forms

Invalid consent: May render procedure legally vulnerable
Regulatory exposure: State enforcement or licensing review
Civil liability: Potential malpractice claims
Billing complications: Insurance denials or audit issues
Privacy breach: Improper storage can violate HIPAA
Loss of evidence: Missing timestamps impair defense in disputes

Representative e-signature pricing and capability comparison

Compare core price points and high-level capabilities to inform vendor selection; signNow is shown first to reflect its available tiers and usage pricing.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes — 7-day trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions and practical answers

Common operational and legal questions about completing, signing, storing, and validating the Alaska Informed Consent for Abortion are addressed below.


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