Provider Forms Archives

Adult Enhanced Care Management Provider Referral Form (age 21 and over)

For adult referrals to Enhanced Care Management (ECM) Services, providers should complete this referral form.

Allied Health Professional Credentialing Application

If you are interested in becoming an Alliance provider, visit the Join our Network page.

Authorization Status Request

Providers can use this form to check the status of an authorization request.

California Advance Health Care Directive Form

These advance directive forms are easy for patients to read and understand.

California Participating Practitioner Application

If you are interested in becoming an Alliance provider, visit the Join our Network page.

Care Management Referral Form

Providers can use this form for referrals to Care Management (CM) Services, including Complex Case Management and Care Coordination.

Carelon Care Management Referral Form

Providers can complete this form to refer a member to local behavioral health care coordination services.

Carelon Diagnostic Evaluation Form (Medi-Cal)

Completed by physician, pediatrician, neurologist or licensed clinical psychologist (M.D./D.O./Ph.D./Psy.D.).

Carelon Primary Care Provider (PCP) Referral Form

Providers can use this form to request clinical decision support, behavioral health treatment/applied behavioral analysis services, or to refer a member for outpatient behavioral health or care management services.

Certification Regarding Debarment Suspension, Ineligibility and Voluntary Exclusion

Providers can send this form to the Alliance with their signed Services Agreement.

Certification Regarding Lobbying – Exhibit D(F) Att 1 and 2

Providers receiving payments under a Services Agreement of $100,000 or more are required to submit the Certification Regarding Lobbying form to the Alliance.

Community Based Adult Services (CBAS) Inquiry Form

Providers can use this form to inquire about CBAS services for Alliance members.

Community Supports: Environmental Accessibility and Adaptability (EAA) Provider Referral Form

For referrals to Community Supports Services (CS), providers should complete this referral form.

Community Supports: Housing Provider Referral Form

For referrals to Community Supports Services (CS), providers should complete this referral form.

Community Supports: Meals Provider Referral Form

For referrals to Community Supports Services (CS), providers should complete this referral form.

Community Supports: Personal Care and Home Maker Services and Respite Services for Caregivers Provider Referral

For referrals to Community Supports Services (CS), providers should complete this referral form.

Consent for Sterilization or Hysterectomy Sample Form

Providers can use this sample form to obtain consent for sterilization or a hysterectomy. Providers are free to duplicate this form and add their letterhead.

Corrected Claim Submission Form

Providers can use this form to submit corrected claims. The form must be completed in full and the claim must be attached. To prevent delays in processing, please do not staple the claim to the form.

Credit Balance Report

Participating hospital providers are required to complete and submit this form to the Alliance on a quarterly basis.

DHCS Facility Site Review (FSR) Checklist

Refer to the DHCS Facility Site Review (FSR) Checklist to help prepare for facility site reviews.

DHCS Medical Record Review (MRR) Checklist

Refer to the DHCS Medical Record Review (MRR) Checklist to help prepare for medical record reviews.

Doula Provider Application

If you are interested in becoming an Alliance provider, visit the Join our Network page.

Durable Medical Equipment Provider Application

If you are interested in becoming an Alliance provider, visit the Join our Network page.

EDI Claims Enrollment Form

This application is used to enroll providers as Trading Partners for various EDI transactions, such as 837 Electronic Claims Submission, 835 Electronic Remittance Advice and others.

Face-to-Face Interpreter Request Form

Prior approval is required to access all face-to-face interpreter services.

FSR Critical Elements: Interim Monitoring Form

Please complete the self-assessment of your facility’s compliance to the DHCS Critical Element Criteria.

Gender-Affirming Services Attestation Form

Please use this form to confirm if you deliver Gender-Affirming Services (but not limited to the services listed in Section 1367.28.) to Alliance members.

Health Programs Referral Form

To refer an Alliance member to one of our programs, please complete the Health Programs Referral Form and fax it to Alliance Health Programs.

Hyaluronic Acid Derivatives Prior Authorization Information Request

Please fax this completed form, along with the Prior Authorization Form/TAR, to the Alliance Pharmacy Department at (831) 430-5851.

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.

Interpreter Services Quality Assurance Form

To report any concerns or issues with our language assistance services, please complete our Interpreter Services Quality Assurance Form.

Locum Tenens Notification Form

Providers can use this form to notify the Alliance of all locum tenens before they render services to Alliance members. Locum tenens are providers who temporarily take the place of, or cover, for another provider.

Long Term Care Treatment Authorization Request

Providers can use this form to request authorization for long term care.

Medi-Cal Provider-Preventable Conditions Reporting Portal

Providers are required to report provider-preventable conditions to DHCS within five working days of discovery via their secure online reporting portal.

Medical Clearance for General Anesthesia or IV Sedation for Dental Procedures

Dental providers can use this form to obtain feedback from an Alliance member’s primary care provider (PCP) regarding the use of general anesthesia or IV sedation for dental procedures.

Medication Management Agreement (MMA)

Primary care providers may use this form to create a Medication Management Agreement for their members. Forms are available in English, Spanish and Hmong.

Member Grievance Form – IHSS

Providers can download and print Member Grievance Forms for members to submit a complaint

Member Grievance Form – Medi-Cal

Providers can download and print Member Grievance Forms for members to submit a complaint

New Provider Attestation Form

After reviewing the information acknowledge that you have completed the training. Please note that the review must be completed prior to the 10th business day of the month.

New Provider ECM/Community Supports Training Sign Off Form

After reviewing the information acknowledge that you have completed the training.

Non-Physician Medical Practitioner Application

If you are interested in becoming an Alliance provider, visit the Join our Network page.

Organizational Provider Application

If you are interested in becoming an Alliance provider, visit the Join our Network page.

Other Health Coverage (OHC) Referral Form

Providers can use the OHC Referral Form to report an Alliance member’s other health coverage.

Outpatient Clinical Laboratory Provider Application

If you are interested in becoming an Alliance provider, visit the Join our Network page.

Patient Complaint/Grievance Tracking Log

Providers can use this form to track patient requests for complaint/grievance forms.

Physician Certification Statement of Medical Necessity for NEMT

Providers are required to complete this form for each member requiring non-emergency medical transportation (NEMT) before transportation can be approved.

Physician Orders for Life-Sustaining Treatment (POLST)

The Alliance encourages providers to have conversations on end-of-life planning that occurs with seriously ill patients, allowing them to choose the treatments they want and helping ensure that their wishes are honored by medical providers.

Prescription Drug Prior Authorization or Step Therapy Exception Request Form

Use this form to submit prescription drug prior authorization requests for Alliance Care IHSS members.

Prior Authorization Information Request for Injectable Drugs

Use this form for chemotherapy, HCPCS J-code requests and other IV medication requests administered by the physician/hospital.

Procedure Reimbursement Rate Request

Contracted providers can use this form to request reimbursement rate information from the Alliance. Please read the instructions tab in its entirety prior to filling out and submitting the form.

Provider Change Request (PCR)

Providers can use this form to make simple changes to an existing prior authorization.

Provider Directory Information Attestation Form

Senate Bill 137 requires the Alliance to solicit updated information from providers on a regular basis to ensure that the most accurate data for your practice is included in our Provider Directories.

Provider Identified Overpayment Form

Providers can use this form to report an overpayment made by the Alliance.

Provider Information Change Form

Keeping the Alliance informed of changes to your practice will ensure correspondence is mailed to a correct address, payments are accurately paid, and only current staff have access to information in the Provider Portal.

Provider Inquiry Form

Providers can use this form to file a dispute with the Alliance.

Provider Portal Account Request Form

In order to set up a Provider Portal account, providers are required to read and accept the Health Information Sharing Agreement.

Request for Administrative Member Status

Providers can use this form for physician verification of diagnosis/plan of treatment.

Request for Member Reassignment Form

Complete this form to request that an Alliance member be reassigned to a new primary care provider (PCP).

Request for Provider Information

The Alliance must have this completed form and a W-9 on file to process claims and/or authorizations.

Synagis Statement of Medical Necessity

Providers who wish to administer Synagis in their office are required to submit the Statement of Medical Necessity along with the prior authorization request.

Transportation Provider Application

If you are interested in becoming an Alliance provider, visit the Join our Network page.

Transportation Services Request Form

Providers can use this form to request non-emergency medical transportation (NEMT) for Alliance members.

Treatment Authorization Request (TAR)

Providers can use this form to request authorization for outpatient services, out-of-area authorized referrals and durable medical equipment requests.

Youth Enhanced Care Management Provider Referral Form (age 20 and under)

For youth referrals to Enhanced Care Management (ECM) Services, providers should complete this referral form.

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