Request Personal Representative

Fill out this form to request a personal representative. You can choose a personal representative to make health care decisions on your behalf. This person will have access to all of your personal health information. If you have questions, contact Member Services at 800-700-3874, ext. 5505.

Please mail back to:
Alliance Member Services
P.O. Box 660015
Scotts Valley, CA 95067

Or email: [email protected]
Or fax: 831-430-5856

Read the instructions on how to download and fill out a form.

Open Personal Representative Request Form