Member Care Connection Questionnaire By sharing some basic health information, we can help maximize your benefits once you become a member. This enables you to avoid potential delays in care or prescription refills. Your responses will allow us to provide support tailored to your medical needs. For additional support, please call our Client Services at (866) 403-2785.Do you or your dependent(s) have any medical or surgical procedures planned for the remainder of 2024?(Required) Yes No If yes, please know that an Alliant Case Manager (usually a nurse) helps manage health care services, especially if many procedures and office visits are involved.Would you like a case manager to reach out to you for assistance?(Required) Yes No Are you or your dependent(s) taking prescription medications that require approval from your current health plan?(Required) Yes No Tell us more about your planned procedure(s). Our team will use this information you provide to ensure that your procedure goes as smoothly as possible.Procedure InformationMember Name (Subscriber/Dependent)Procedure NameProvider Name and Phone/Email (if known)Procedure InformationMember Name (Subscriber/Dependent)Procedure NameProvider Name and Phone/Email (if known) Please list the name(s) of your prescribed medication(s) that require approval from your current health plan. Our team will use the information you provide to conduct appropriate outreach about the process regarding this medication.Name of Medication(s)Provider's Name and Phone (if known) Name(Required) First Last Email Phone(Required)Any additional information we might need to best help you maximize your benefits?
