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Member Forms

Online Self-Service

Change Primary Doctor

Please fill out the Provider Selection Form online or call the Member Services department at 800-700-3874.
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

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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 (PHI). The form is available in English, Spanish and Hmong.
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 fill out the Health Information Exchange (HIE) Opt-Out Form to request that the Alliance does not electronically share your health information with other organizations. You can fill out the Record Access Request Form to get a copy of your protected health information from the Alliance.
Request Personal Representative

Fill out this form to designate a personal representative. A personal representative can make health care decisions on your behalf. If you have questions, contact Member Services at 831-430-5505 or 800-700-3874, ext. 5505.
Update Other Health Insurance

If you have Medi-Cal and other health insurance, you will need to update your information with your local county either by phone or online.
Update Personal Information

You will need to contact both the Alliance and your county’s Medi-Cal office if you move or change your phone number. Fill out this form to update your address and/or phone number with the Alliance.
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.