We are here to help you

To view and download Alliance member forms, please select your preferred language.

If you have any questions or would like to request materials in your preferred language or alternative format, please complete our online Contact Us Form or call:

Authorized Representative (AOR) Form

As an Alliance member, you can choose to have a person be your authorized representative (AOR). Your AOR can communicate with us on your behalf. We will work with this person just as we would with you. Your AOR may act for you in most health care matters, and receive and disclose your Personal Health Information (PHI).

To request an AOR, please complete the form below:
English | Spanish | Chinese | Vietnamese

Compliance Incident Form

The Compliance Incident Report form is confidential and may be used to report any suspicious incidents you see or hear. (I.e. HIPAA privacy health information disclosures, fraud, waste and abuse, or any compliance issues.)

To report a potential compliance issue, please complete the form below:
English | Spanish | Chinese | Vietnamese

You may also report by calling the Alliance Compliance Department Hotline. Callers can choose to report issues anonymously. The Alliance Compliance Hotline is accessible 24 hours a day, 7 days a week, toll-free at 1.855.747.2234.

For more information, please view the Compliance page.

For examples of health care fraud, please view Fraud Prevention.

Grievance Form

Your satisfaction is important to us! If you have a problem with the Alliance, you have the right to make a complaint. This is also called filing an appeal or a grievance. An appeal is when you ask for review of an “Adverse Benefit Determination.”

If you have a grievance or appeal, you may file it by phone, online, or by filling out the Alliance Member Grievance form. Your provider may also file an appeal for you.

To file a grievance, please complete the form below:
English | Spanish| Chinese | Vietnamese| Tagalog

For more information, please view Grievances & Appeals.

Immunization Registry Form

To start or decline sharing immunization (shot)/tuberculosis (TB) information, please complete the form below:
English | Spanish | Chinese | Vietnamese

Request for Reimbursement Form

If you paid for a service that you think the Alliance should cover, you will need to complete a Member Request for Reimbursement Form and tell the Alliance in writing why you had to pay. You will need to include a copy of the itemized bill and proof of payment (such as receipts) with your request. The Alliance will review your request to find out if you can get money back. The Alliance will accept and review requests for reimbursement for a health expense that is received within 180 calendar days after the date the bill was paid.

Please use one (1) form for each health expense you are asking the Alliance to reimburse to you.

To request for a reimbursement, please complete the form below:
English | Spanish | Chinese | Vietnamese

To request for a pharmacy reimbursement, please complete the form below:
English | Spanish | Chinese | Vietnamese 

 

Wellness Program & Materials Request Form

We offer materials and tools in alternative formats, programs in different languages, and classes throughout Alameda County.

To request paper copies of materials and program listings, please complete the form below:
English | Spanish | Chinese | Vietnamese

For more information, please visit the Live Healthy page.