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. 

  Send Application with Services Agreement
Send Services Agreement Only

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

For which lines of business are you applying?*

Alliance Medi-Cal
Alliance Care IHSS

Primary Office Address:

Street Address:*
Address (Line 2):
City:*
State:*	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:*
Phone:*
E-mail:*
Contact Name:*

Secondary Office Address:

Street Address:
Address (Line 2):
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Phone:
Contact Name:
E-mail:

Mailing Address:

Same as Primary Office Address

Street Address:*
Address (Line 2):
City:*
State:*	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
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.

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