Member Forms – Find a Form

Please fill out the Choose Primary Doctor form online and Member Services will review your request.

You can fill out this form to request that confidential communications that contain your medical information be delivered to an alternate address, email, or telephone number.

The Alliance will acknowledge receipt of your complaint or appeal in writing within five (5) calendar days, and respond to your complaint or appeal in writing within thirty (30) calendar days.

If you have Medi-Cal and other health insurance, you must update your other insurance information every time it changes.

Fill out the Member Reimbursement Claim Form to ask for reimbursement for covered services. If you have any questions or need assistance with this form, please call our Member Services department at 800-700-3874.

This form should be completed by a parent or guardian to consent to non-emergency medical transportation for a minor.

The Alliance can mail you an Alliance Member ID Card, Member Handbook or printed Provider Directory. It can take up to 10 business days to receive the requested material.

You can make a privacy request if you want to get a copy of your health information or limit how your information is shared with other organizations.

Fill out this form to request a personal representative. You can choose a personal representative to make health care decisions on your behalf.

If you have changes to your address or phone number, you will need to contact both the Alliance and your county’s Medi-Cal office to update your contact information.

If you have Medi-Cal and other health insurance, you must update your other insurance information every time it changes.