For assessment and treatment as medically necessary.
If you are interested in becoming an Alliance provider, visit the Join our Network page.
Providers can use this form to check the status of an authorization request.
Providers can complete this form to refer a member to local behavioral health care coordination services.
Completed by physician, pediatrician, neurologist or licensed clinical psychologist (M.D./D.O./Ph.D./Psy.D.).
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.
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 services. The form includes a page in Spanish for members to authorize sharing of information between their behavioral health provider and PCP.
These advance directive forms are easy for patients to read and understand.
If you are interested in becoming an Alliance provider, visit the Join our Network page.
Providers can use this form for referrals to Care Management (CM) Services, including Complex Case Management and Care Coordination.
Providers can send this form to the Alliance with their signed Services Agreement.
Providers receiving payments under a Services Agreement of $100,000 or more are required to submit the Certification Regarding Lobbying form to the Alliance.
For assessment and treatment as medically necessary.
If you are interested in becoming an Alliance-approved clinical health education (CHE) provider, submit this application.
Providers can use this form to inquire about CBAS services for Alliance members.
For referrals to Community Supports Services (CS), providers should complete this referral form.
For referrals to Community Supports Services (CS), providers should complete this referral form.
For referrals to Community Supports Services (CS), providers should complete this referral 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.
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.
Participating hospital providers are required to complete and submit this form to the Alliance on a quarterly basis.
Refer to the DHCS Facility Site Review (FSR) Checklist to help prepare for facility site reviews.
Refer to the DHCS Medical Record Review (MRR) Checklist to help prepare for medical record reviews.
If you are interested in becoming an Alliance provider, visit the Join our Network page.
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.
For referrals to Enhanced Care Management (ECM) Services, providers should complete this referral form.
Prior approval is required to access all face-to-face interpreter services.
Please complete the self-assessment of your facility’s compliance to the DHCS Critical Element Criteria.
To refer an Alliance member to one of our programs, please complete the Health Programs Referral Form and fax it to Alliance Health Programs.
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.
To report any concerns or issues with our language assistance services, please complete our Interpreter Services Quality Assurance 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.
Providers can use this form to request authorization for long term care.
Providers are required to report provider-preventable conditions to DHCS within five working days of discovery via their secure online reporting portal.
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.
Primary care providers may use this form to create a Medication Management Agreement for their members. Forms are available in English, Spanish and Hmong.
Providers can use this form to inform the Alliance Member Services department that an Alliance member did not keep a scheduled appointment. Providers can also quickly report member no-shows on the Alliance Provider Portal.
Providers can download and print Member Grievance Forms for members to submit a complaint
Providers can download and print Member Grievance Forms for members to submit a complaint
Providers can use these templates to notify members when a reassignment has been requested. Templates are available in English, Spanish and Hmong.
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.
After reviewing the information acknowledge that you have completed the training.
If you are interested in becoming an Alliance provider, visit the Join our Network page.
If you are interested in becoming an Alliance provider, visit the Join our Network page.
Providers can use the OHC Referral Form to report an Alliance member’s other health coverage.
If you are interested in becoming an Alliance provider, visit the Join our Network page.
Providers can use this form to track patient requests for complaint/grievance forms.
Providers are required to complete this form for each member requiring non-emergency medical transportation (NEMT) before transportation can be approved.
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.
Use this form to submit prescription drug prior authorization requests for Alliance Care IHSS members.
Use this form for chemotherapy, HCPCS J-code requests and other IV medication requests administered by the physician/hospital.
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.
Complete the three steps on this checklist to become approved as an Alliance Clinical Health Education Provider for diabetes prevention and self-management education.
Providers can use this form to make simple changes to an existing prior authorization.
This form is used to report suspected HIPAA Events, or for suspected Fraud, Waste, or Abuse (FWA).
Providers can use this form to report an overpayment made by the Alliance.
Providers can use the Provider Information Change Form to update contact and practice information, including the provider’s address, phone number, contact information, payment address and tax ID number.
Providers can use this form to file a dispute with the Alliance.
In order to set up a Provider Portal account, providers are required to read and accept the Health Information Sharing Agreement.
Complete this form to request that an Alliance member be reassigned to a new primary care provider (PCP). Please follow the Procedure to Request Member Reassignment.
The Alliance must have this completed form and a W-9 on file to process claims and/or authorizations.
Providers who wish to administer Synagis in their office are required to submit the Statement of Medical Necessity along with the prior authorization request.
If you are interested in becoming an Alliance provider, visit the Join our Network page.
Providers can use this form to request non-emergency medical transportation (NEMT) for Alliance members.
Providers can use this form to request authorization for outpatient services, out-of-area authorized referrals and durable medical equipment requests.
