Member Reimbursement Claim Form

Instructions: How to fill out the Member Reimbursement Claim Form

Central California Alliance for Health (the Alliance) will pay you directly if you had to pay for covered services. Services may be reviewed for medical necessity before we pay for them. If approved for payment, the Alliance will send you a check. If services are not eligible for reimbursement, the Alliance will send you a letter.

If you have any questions or need assistance with this form, please call our Member Services department at 800-700-3874. Fill out a separate form for each member who is asking for reimbursement for covered services and for each doctor and/or facility.