Provider Selection Form

In the form below, please fill in each box. If you are ordering for yourself, please just fill in all of the information about you. If you are ordering for other people in your family, please fill out their information also.

Fields with an asterisk (*) are required.

First Name:*
Last Name:*
Alliance ID or SSN:*
Date of Birth:*
Street Address:*
Address (Line 2):
City:*
State:*
Zip Code:*  
Home Phone:*  

Please provide the following Primary Care Provider (PCP) information:

Current PCP Name:*
New PCP Name:*
New PCP NPI Number:*

Are there other members of your family that want to change their Alliance PCP?


Please provide the following information for another family member to change their PCP:

First Name:
Last Name:
Alliance ID or SSN: Note: SSN is not valid for Healthy Kids
Date of Birth:
Street Address:
Address (cont.):
City:
State:
Zip Code:  
Home Phone:  

Please provide the following Primary Care Provider (PCP) information:

Current PCP Name:
New PCP Name:
New PCP NPI Number:

Central California Alliance for Health cannot guarantee that Providers applying to contract with the Alliance shall become contracted Providers. Providers are subject to reviews based upon network adequacy and Alliance qualification standards.