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08/01/2023
Updated Provider Request Forms Available on the Website
Alliance has updated two frequently-used provider request forms:
Notice of Change: this form should be used by existing Alliance Health network providers who need to submit a change to their records in ACS.
Comprehensive Provider Application Request (PAR): this form should be used as outlined below.
- New providers requesting to join the Alliance Health network
- Out-of-network providers submitting a single case application
- Contracted providers seeking to add new sites or service codes
Both forms should be completed and emailed to Enrollment@AllianceHealthPlan.org to initiate your request.
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