Member Forms

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

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

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

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.

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.

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 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.

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.

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.

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.