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Employer Forms and Documents

For your convenience, we have made the forms below fillable. To enable your computer to edit the forms, follow these instructions.

Forms

  • SoloCare Individual Enrollment Application/Change in Coverage Form
  • SimpleCare Employee Enrollment Application
  • SimpleCare Employee Enrollment Application with Medical 
  • Member Accident Injury Form
  • Group Admin Form
  • Member Medical Claim Form (12-14-16)
  • Other Insurance Questionnaire
  • Authorization to Share Protected Health Information (PHI)
  • Group & Individual Auto Pay Form  (Spanish)
  • Group 834 EDI Request Form
  • SimpleCare Member Change Form

Documents

  • Nurse Line Information
  • Alliant Health Plans Covers Certain Preventive Care Services
  • SimpleCare Certificates of Coverage
  • SoloCare Certificates of Coverage
  • Important Contact Information
  • Reporting Life Changes to Healthcare.gov
  • Alliant ID Card Mobile App Instruction Guide
  • Alliant Network Provider Search Instructions 
  • Procedures Requiring Prior Authorization
  • Surprise Billing and Alliant Health Plans’ Response
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    Alliant Health Plans is committed to maintaining a broad and varied provider network to offer our members. As a part of this process, we often experience changes in the network.  As of October 1, 2021, Emory Healthcare (facilities and providers) will be out of network for Alliant. For assistance finding an in-network, please utilize the Find a Provider feature on our website or call Customer Service at (866) 403-2785.

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