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Member Forms – Find a Form

Online Self-Service

  • Choose Primary Doctor

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

  • Community Support Services Member Referral Form

    For referrals to Community Support (CS) services, fill out this referral form and have your doctor fax it to the Enhanced Care Management team at 831-430-5819

  • Confidential Communications Request Form

    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.

  • Enhanced Care Management (ECM) Member Referral Form

    For referrals to Enhanced Care Management (ECM) Services, fill out this referral form and have your doctor fax it to the Enhanced Care Management team at 831-430-5819

  • Grievance Form

    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.

  • Information Release

    Providers and community partners can use this form to request that the Alliance release information related to an Alliance member that is considered to be protected health information.

  • Insurance Information

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

  • Member Reimbursement Claim Form

    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.

  • Order ID Card, Member Handbook and Provider Directory

    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.

  • Privacy Request

    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.

  • 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.

  • Update Personal Information

    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.

  • Whole Child Model Family Advisory Committee Application Form

    The Whole Child Model Family Advisory Committee (WCMFAC) represents the needs and concerns of families of CCS-eligible children. Fill out this form to apply to join the committee.