Form Library
Note: Some links on this page may require Adobe Reader or Microsoft Word
Care Based Incentives (CBI) Forms
Provider CBI Forms - Effective 1/1/11-12/31/11 for 2011 Dates of Service.
• Asthma Action Plan (English or Spanish or Hmong) – PCPs must use this form to create an Asthma Action Plan for their members aged 3 - 18. PCPs that complete and fax this form to the Alliance may be eligible for reimbursement through our CBI program.
• Body Mass Index Form – PCPs must use this form to report their member’s Body Mass Index (BMI) to the Alliance for members aged 3 - 18 with a BMI at or above the 90th percentile. PCPs that complete and fax this form to the Alliance may be eligible for reimbursement through our CBI program.
Instructions for Calculating BMI
• Medication Management Agreement (English or Spanish or Hmong) – PCPs must use this form to create a Medication Management Agreement for their members. PCPs that complete and fax this form to the Alliance may be eligible for reimbursement through our CBI program.
Member CBI Forms - Effective 1/1/11-12/31/11 for 2011 Dates of Service.
The following CBI forms intended for member use are made available here for providers to see in case they receive questions from members.
• Awareness of Access Rules Quiz (English or Spanish or English and Hmong or Hmong) – New members will receive this quiz from the Alliance in their new member welcome packet. Members who complete and submit this quiz to the Alliance will be eligible to enter a raffle for a chance to receive a $50 gift card.
• Prenatal Form (English or Spanish or Hmong) – Providers may be asked to complete this form after their member’s first prenatal visit. Members who complete and submit this form to the Alliance will be eligible to receive a $25 gift card. Members only qualify if the visit is in their first trimester. The Alliance is reliant on the PCP to make the determination that the member is in their first trimester.
• Postpartum Form (English or Spanish or Hmong) – Providers may be asked to complete this form after their member’s postpartum visit. Members who complete and submit this form to the Alliance will be eligible to receive a $25 gift card.
• What To Do When Your Child Gets Sick Quiz (English or Spanish) – Parents/guardians of members who are young children may receive the book “What To Do When Your Child Gets Sick” from their child’s PCP or from the Alliance. They will also receive a quiz, asking them questions about information contained in the book. Parents/guardians who complete and return the quiz to the Alliance will be eligible to enter a raffle for a chance to win a $50 gift card.
Provider CBI Forms - Effective 1/1/12-12/31/12 for 2012 Dates of Service.
Under DevelopmentForms for Specific Health Education Programs
Healthy Breathing for Life
• Asthma Action Plan (AAP) - PCPs may use this form to create an Asthma Action Plan for their members aged 3-56. PCPs who complete and fax the AAP to the Alliance may be eligible for payment through our CBI program. Click here to download the AAP in English or Spanish or Hmong.
Healthy Weight for Life
• Initial Referral and 6-Month and 12-Month Follow Up Referral - PCPs must use these forms to refer members to the Healthy Weight for Life program and report members' Body Mass Index (BMI) to the Alliance. This program is for members ages 2-18 with a BMI at or above the 85th percentile. PCPs who complete and fax these forms to the Alliance may be eligible for payment through our CBI program. Click below to download the appropriate referral form, based on the member's language. (Please fax only the completed referral form to the Alliance, not the Rx form. Give the completed Rx form to the patient and keep a copy in the patient's file.)
Initial Referral with English Rx Form
Initial Referral with Spanish Rx Form
Initial Referral with Hmong Rx Form
6-Month and 12-Month Follow Up Referral with English Rx Form
6-Month and 12-Month Follow Up Referral with Spanish Rx Form
6-Month and 12-Month Follow Up Referral with Hmong Rx Form
Instructions for Calculating BMI
CDC BMI Percentile Calculator for Child and Teen
Other Provider CBI Forms
• Medication Management Agreement (MMA) - PCPs may use this form to create a Medication Management Agreement for their members. PCPs who complete and fax this form to the Alliance may be eligible for payment through our CBI program. Click here to download the MMA in English or Spanish or Hmong.
Member CBI Forms - Effective 1/1/12-12/31/12 for 2012 Dates of Service.
Under DevelopmentThe following CBI forms are intended for member use. Providers may view and download these forms if they receive questions from members.
Forms for Specific Health Education Programs
Healthy Moms And Healthy BabiesOther Member CBI Forms
• Early Prenatal Care Form - Providers may be asked to complete this form after their member's first prenatal visit. Members who have a prenatal visit within their first twelve weeks of pregnancy can complete and submit this form to the Alliance to receive a $25 gift card. Members can also qualify for the gift card if they are pregnant and get a prenatal visit within 42 days of becoming an Alliance member. Click here to download the form in English or Spanish or Hmong.
• Postpartum Form - Providers may be asked to complete this form after their member's postpartum visit. Members who have a postpartum visit within 21-56 days after the birth of their baby can complete and submit this form to the Alliance to receive a $25 gift card. Click here to download the form in English or Spanish or Hmong.
• Awareness of Access Rules Quiz - New members will receive this quiz from the Alliance in their new member welcome packet. Members who complete and submit this quiz to the Alliance will be eligible to enter a raffle for a chance to receive a $50 gift card. Click here to download the form in English or Spanish or English and Hmong or Hmong.
• What To Do When Your Child Gets Sick Quiz - Parents/guardians of young children may receive the book "What To Do When Your Child Gets Sick" from the Alliance. Parents/guardians will also receive a quiz with questions about information in the book. Members who complete and return the quiz to the Alliance will be eligible to enter a raffle for a chance to win a $50 gift card. Click here to download the quiz in English or Spanish.
Other Forms
Claims
• 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 - Electronic Claim Submission - 837 file format – This application is used by providers in order to apply for electronic claims submission.
• Telecommunications Provider and Biller Application/Agreement - Electronic Remittance Advice - 835 file format – This application is used by providers in order to apply for electronic remittance advice receipt. The 835 format is used to transmit claims processed by the Alliance to the provider or their clearinghouse for input into their Accounts Receivable system.
Finance
• Identification of an Overpayment – This form can be used to communicate an overpayment to the Alliance.
• 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
• Authorization Inquiry Form – 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.
• 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.
• Medical Records Forms
Member Services
• 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.
• Need Help with Your HMO? (English and Spanish) – Flyers from California Department of Managed Health Care describing how members can get help regarding their health plan.
Provider Services
• Instructions/forms - Request for Member Reassignment
Instruction on how to complete and submit a "Request for Member Reassignment from Case Management"
Attachment A: Request for Member Reassignment Form
Attachment B: Request for Member Reassignment Procedure
Attachment C: Member Notice Letter (English)
Attachment D: Member Notice Letter (Spanish)
Attachment E: Member Notice Letter (Hmong)
• Member Appointment No-Show Notification – This form is used to inform Member Services that an Alliance member did not keep a scheduled appointment.
• Patient Complaint / Grievance Tracking Log – Form that Physicians/Providers can use to track patient requests for Complaint / Grievance Forms.
• Provider Dispute Form – This form is used by provider to file a dispute with the Alliance.
• Procedure Reimbursement Rates – 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.
• Certification Regarding Lobbying - Exhibit D(F) Att 1 and 2 – If payments to provider under the Services Agreement are $100,000 or more, provider shall submit the "Certification Regarding Lobbying" to the Alliance.
• Certification Regarding Debarment Suspension, Ineligibility and Voluntary Exclusion – Form sent to the Alliance with signed Services Agreement.
• Declaration of Confidentiality – Form sent to the Alliance regarding authorization procedures for release / access of DHS computer files for the Medi-Cal Program, as required by Alliance contract with the State.
• Referral Consultation Request Form (sample only)
This form is for the use of a Primary Care Provider when referring their linked member for specialty care. Referrals to out-of-service-area providers must be approved by the Alliance by submitting a Treatment Authorization Request Form.
• Instructions for completing the Referral Consultation Request Form