Request to Opt-in Form


We are informing you that Alliance contracted providers now have the option of receiving and executing amendments electronically. The Alliance will be utilizing this option for executable amendments this year, and we’d like to confirm if you’d like to participate in this option.

If you have not submitted a Request to Opt-in form yet and are interested in taking advantage of this option with future amendments, please fill out and return the enclosed Request to Opt-in form. Completed forms can be faxed back to the Alliance at (831) 430- 5857 or sent via email to [email protected]

If you have any questions, please contact an Alliance Provider Relations Representative at (800) 700-3874 ext. 5504.

Click image below to open PDF file:

Request to Opt-in Form