Application/Contract Request Form 
for Physicians and Allied Health Professionals

If you would like to receive a Central California Alliance for Health (Alliance) Provider Application and/or Services Agreement, you may submit your request electronically by completing this form. 

 
Name:*
Degree:*
Tax ID:*
Group Name:
Specialty:*
Subspecialty:*
Board Certified:

For which lines of business are you applying?*


Primary Office Address:

Street Address:*
Address (Line 2):
City:*
State:*
Zip Code:*  
Phone:*  
E-mail:*  
Contact Name:*

Secondary Office Address:

Street Address:
Address (Line 2):
City:
State:
Zip Code:  
Phone:  
Contact Name:
E-mail:  

Mailing Address:



Street Address:*
Address (Line 2):
City:*
State:*
Zip Code:*  

The Alliance 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.