Claims Department
• Comments/Suggestions for the Claims Department – Providers can use this form to send comments or suggestions to the Alliance Claims Department.
• Procedure Reimbursements Rates – Providers can use this form to request reimbursement information by identifying procedure codes.
• Interested in Electronic Claims Submission? – This form begins the electronic claims submission process.
• Telecommunications Provider and Biller Application/Agreement (For Electronic Claim Submission) – This application is used by providers in order to apply for electronic claims submission
Finance Department
• Identification of an Overpayment – This form can be used to communicate an overpayment to the Alliance.
• Refund – This form is sent to the Alliance with a refund payment.
• Credit Balance Report – This form needs to be filled out quarterly and sent to the Alliance.
• OHC Referral Form – This form needs to be filled out for a member's Other Health Coverage.
Health Services Department
• Which CPT Code Requires a TAR? – This form is used by providers to check if a CPT code(s) requires a Treatment Authorization Request.
• Request for Administrative Member Classification – This form is used by providers requesting that an Alliance member be made an administrative member
• Consent for Sterilization or Hysterectomy Sample Form – This is a sample form to obtain consent for sterilization or a hysterectomy. Offices can feel free to duplicate this form and add their letterhead.
• Asthma Action Plan, English or Spanish – This form is used by providers participating in the Quality Based Incentive for Asthma Management. FAX form to (831) 430-5851 attn: Health Services Administrative Assistant.
• Medication Agreement, English or Spanish – This form may be used by providers participating in the Quality Based Incentive for Chronic Pain Management. FAX form to (831) 430-5851 attn: Health Services Administrative Assistant.
• Advance Directives Form, English or Spanish – This free advance directives form is easy for patients to read and understand.
• Staying Healthy Assessment Order Form – Use to order bulk quantities of the Staying Healthy Assessment forms and patient handouts. To print Staying Healthy forms and handouts yourself, go to the Staying Healthy Assessment page for .pdf versions in seven languages.
• Health Education Materials Order Form – Use to order free patient education materials on asthma and diabetes. See form for titles currently available.
Member Services Department
• Member Complaint Packet – This file can be printed out and handed to members who are interested in filing a complaint to the Alliance’s Grievance Coordinator. This file contains both English and Spanish versions of the Frequently Asked Questions and Member Rights and Complaint Form.
• Member Appointment No-Show Notification – This form is used to inform Member Services that an Alliance member did not keep a scheduled appointment.
Provider Services Department
• Instructions - Deletion Request Procedure – Instructions on how to complete and submit the “Request for Deletion of Patient from Case Management List” form.
• Request for Deletion of Patient from Case Management List – This form is used by Primary Care Providers to request that an Alliance member be removed from their case management list.
• Provider Dispute Form – This form is used by provider to file a dispute with the Alliance.
• Provider Procedure Reimbursement Rates Request Form – This form is used by provider to request reimbursement rates information from the Alliance.
• Provider Eligibility Verification FAX Form – This form is used to FAX the member’s name, and date of birth, or the member’s Alliance ID or Social Security Number (Please note that the SSN can only be used to verify eligibility for Alliance Medi-Cal or Alliance Care IHSS members only), the date of service that you are checking eligibility for. The Alliance will fax you back the form indicating whether or not the member is/was eligible, what plan the member is/was enrolled in and who the PCP is/was.
• Provider Information Change Form – This form is used to update contact and practice information. Information includes provider address, phone number, contact information, payment address, and tax ID number.
• Provider Applications – If you are interested in becoming an Alliance provider, visit our Joining our Network page.