Adult Enhanced Care Management Member Referral Form (age 21 and over)
For adult referrals to Enhanced Care Management (ECM) Services.
Online Self-Service
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Choose Primary Doctor
Please fill out the Choose Primary Doctor form online and Member Services will review your request.
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Community Supports: Environmental Accessibility and Adaptability (EAA) Member Referral Form
For referrals to Community Support services.
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Community Supports: Medically Tailored Meals Member Referral Form
For member medically tailored meals member referrals to Community Support services.
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Community Supports: Member Housing Referral Form
For member housing referrals to Community Support services.
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Community Supports: Member Personal Care and Homemaker Services and Respite Services Referral Form
For Personal Care and Homemaker Services and Respite Services referrals to Community Support services.
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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.
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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.
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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.
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Insurance Information
If you have Medi-Cal and other health insurance, you must update your other insurance information every time it changes.
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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.
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Non-Emergency Medical Transportation Minor Consent Form
This form should be completed by a parent or guardian to consent to non-emergency medical transportation for a minor.
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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.
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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.
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Records Access Request Form
Please fill out the Records Access Request Form to obtain a copy of your Alliance medical records.
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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.
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Update Contact 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.
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Update Other Health Insurance
If you have Medi-Cal and other health insurance, you must update your other insurance information every time it changes.
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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.
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Youth Enhanced Care Management Member Referral Form (age 20 and under)
For youth referrals to Enhanced Care Management (ECM) Services.
