Broker Forms and Documents

This section contains the forms and documents currently in use at Alliant.
For your convenience, we have made the forms below fillable. To enable your computer to edit the forms, follow these instructions.

For a complete list of online Member forms and documents please go to the Members Forms and Documents page.

Broker Forms and Documents

 

Broker Forms

Broker Auto Pay form

Authorization to Share Personal Health Information (PHI)

Broker of Record (BOR) Enrollment On and Off Marketplace form 

Alliant Health Plans Business Associate Agreement (BAA) Addendum

Broker Resources

New Group General Guidelines

Broker Appointment Packet

2021 Cobra Guide

 

 

Alliant Health Plans – Medical

 

Members Resources

Nurse Line Information

Alliant Network Provider Search Instructions 

PHCS Network Provider Search Instructions

PHCS Primary Carve Out List

PHCS Dual Network Carve Out List

Member Direct Reimbursement Rx Claim form

Alliant ID Card Mobile App Instruction Guide

Important Contact Information

Procedures Requiring Prior Authorization

Alliant Health Plans Covers Certain Preventive Care Services

SoloCare Forms and Documents

SoloCare Individual Enrollment Application & Change in Coverage Form

SoloCare Certificates of Coverage

Individual and Group Auto Pay form

Member Medical Claim Form

Member Accident Injury form

SimpleCare Forms and Documents

Group Employer Enrollment Application

Group Health Care Contract 

SimpleCare Employee Enrollment Form

SimpleCare Employee Enrollment Form with Medical

Group and Individual Auto Pay form (Spanish)

SimpleCare Certificates of Coverage

Group 834 EDI Request Form

SimpleCare Member Change Form

 

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