CA Alameda Alliance for Health Medication Request Form 2013-2025 free printable template

Alameda Alliance for Health Medication Request Form Attn: Prior Authorization Department 200 Stevens Drive Philadelphia, PA 19113 Phone (Medical/Group Care): 1-855-508-1713 Phone (AllianceSELECT):

How to fill out alameda medication form

How to fill out CA Alameda Alliance for Health Medication Request Form

1. Obtain the CA Alameda Alliance for Health Medication Request Form from the official website or your healthcare provider.
2. Fill in the patient's personal information, including name, date of birth, and member ID.
3. Provide the prescribing physician's details, including name, contact information, and NPI number.
4. Specify the medication requested, including the name, dosage, frequency, and duration of therapy.
5. Include a description of the medical necessity for the medication, such as diagnosis and treatment history.
6. Attach any relevant medical records or documents that support the request.
7. Review the completed form for accuracy and completeness.
8. Sign and date the form, and ensure that the physician also signs it if required.
9. Submit the form as instructed, either by fax or through the online portal, as appropriate.

Who needs CA Alameda Alliance for Health Medication Request Form?

1. Members of the CA Alameda Alliance for Health who require medication that needs prior authorization.
2. Healthcare providers submitting medication requests on behalf of their patients.
3. Patients with specific medical conditions requiring medications not typically covered without prior approval.

People Also Ask about medication formulary medically

How do I get a new Alameda Alliance card?

If you do not get your Alliance Member ID card after a few weeks of enrolling, or if your card is damaged, lost or stolen, you can: Order a new card online by filling out the Replace ID Card form. Call Member Services at the Alliance to request a new one.

How do I contact Alameda Alliance for Health?

Call your prospective doctor or clinic, medical group, independent practice association, or call Alameda Alliance for Health at 510.747. 4567 to ensure that you can obtain the health care services that you need.

What is the maximum income to qualify for Medi-Cal 2023?

In 2023, the MMNA in CA is $3,715.50 / month. If a non-applicant's monthly income is under this amount, income can be transferred to them from their applicant spouse to bring their income up to $3,715.50.

What is the phone number for Alameda Alliance provider?

2021 PROVIDER DIRECTORY If you have a question about the availability of a provider please call Member Services at 510.747. 4567 or 1.877. 932.2738.

What is the income limit for Medi-Cal in Alameda County?

Beginning July 1, 2022, the asset limit for Non-Modified Adjusted Gross Income (Non-MAGI) Medi-Cal programs increased to $130,000 for a household of one person and $195,000 for a household of two people.

Is Alameda Alliance the same as Medi-Cal?

Welcome to the Alliance! Thank you for joining Alameda Alliance for Health (Alliance). The Alliance is a health plan for people who have Medi-Cal. The Alliance works with the State of California to help you get the health care you need.

What is the maximum income to qualify for Medi-Cal assistance in CA?

ing to Covered California income guidelines and salary restrictions, if an individual makes less than $47,520 per year or if a family of four earns wages less than $97,200 per year, then they qualify for government assistance based on their income.

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What is CA Alameda Alliance for Health Medication Request Form?

The CA Alameda Alliance for Health Medication Request Form is a document used by healthcare providers to request authorization for specific medications that may not be covered under a patient's insurance plan without prior approval.

Who is required to file CA Alameda Alliance for Health Medication Request Form?

Healthcare providers or prescribers are required to file the CA Alameda Alliance for Health Medication Request Form on behalf of their patients when seeking prior authorization for medications.

How to fill out CA Alameda Alliance for Health Medication Request Form?

To fill out the CA Alameda Alliance for Health Medication Request Form, the provider must include patient information, medication details, clinical rationale for the request, supporting documentation, and provider contact information.

What is the purpose of CA Alameda Alliance for Health Medication Request Form?

The purpose of the CA Alameda Alliance for Health Medication Request Form is to ensure that medications prescribed to patients are medically necessary and appropriate, while also confirming coverage under the patient's insurance plan.

What information must be reported on CA Alameda Alliance for Health Medication Request Form?

The form must report patient demographics, medication name and dosage, diagnosis, previous treatment history, and any relevant medical documentation supporting the request for the medication.