Member Forms and Documents
Forms
- Member Accident Injury form
- Member Accident Injury Form (Spanish)
- Member Medical Claim form
- Member Medical Claim Form (Spanish)
- Member Direct Reimbursement Rx Claim form
- Member Claim Appeal form
- Member Claim Appeal form (Spanish)
- Authorization to Share PHI
- Authorization to Share PHI (Spanish)
- Individual and Group Auto Pay form
- Individual and Group Auto Pay form (Spanish)
- SoloCare Individual Enrollment Application/Change in Coverage Form
- SoloCare Individual Enrollment Application/Change in Coverage Form (Spanish)
- Serventy Authorization to Share PHI
- Serventy Authorization to Share PHI (Spanish)
- Other Insurance Questionnaire
- Other Insurance Questionnaire (Spanish)
- Pharmacy Mail Order Form
- Continuity Care Request Form
- Continuity Care Request Form (Spanish)
- Covid-19 At Home Test Reimbursement Form
- Covid-19 At Home Test Reimbursement Form (Spanish)
Documents
- Nurse Line Information
- Member Community Resources
- Certificates of Coverage
- Alliant ID Card Mobile App Instruction Guide
- Reporting Life Changes to Healthcare.gov
- Reporting Life Changes to Healthcare.gov (Spanish)
- Alliant Network Provider Search Instructions
- Alliant Network Provider Search Instructions (Spanish)
- PHCS Network Provider Search Instructions
- PHCS Network Provider Search Instructions (Spanish)
- PHCS Primary Carve Out List
- PHCS Primary Carve Out List(Spanish)
- PHCS Dual Network Carve Out List
- Procedures Requiring Prior Authorization
- Procedures Requiring Prior Authorization(Spanish)
- Alliant Health Plans Covers Certain Preventive Care Service
- Alliant Health Plans Covers Certain Preventive Care Service (Spanish)
- Alliant Health Plans’ FAQ for Members on Medical Loss Ratio (MLR)
- Alliant Health Plans’ FAQ for Members on Medical Loss Ratio (Spanish)
- Important Contact Information
- Important Contact Information (Spanish)
- MDLIVE Information
Copyright 2016. Alliant Health Plans, Inc.