ATTENTION LIPs, AGENCIES AND GROUPS PROVIDING OUTPATIENT AND PSYCHIATRIC SERVICES

To help Alliance enhance its online Provider Search tool it is critical that we collect important information from Licensed Clinicians credentialed by Alliance. All contracted provider entities should follow instructions outlined in the Clinician Maintenance User Guide to access an online portal to provide this information about each of your clinicians. This information includes clinician specialties, languages spoken, and sites at which the clinician provides services. Please help us provide more comprehensive and useful information to people in our communities who use the Provider Search when seeking services. DEADLINE FOR SUBMITTING THIS INFORMATION IS JULY 13.

Publications

You can scroll through our most commonly requested publications below, including the Provider Operations Manual, or download them using the link below each preview.

Finance and claim resources, as well as other useful forms and documents, are available for download further down the page.

Use the convenient table of contents to the right to navigate to your destination.

Other Forms and Documents for Providers

Members of the Alliance Provider Network can find other necessary forms, documents and other resources below.

AlphaMCS Access Request
B3 IPRS DD Support Plan
Certification of Need Medicaid Inpatient Psychiatric Service Under Age 21
Client Transfer Tracking Form
DASH-Home Again Application
Emergency Relocation Form
Form QM11
Guidelines for Implementing Core Rules
HIPAA Request for Accounting of Disclosure
HIPAA Request for Alternative Means of Communication
HIPAA Request for Restrictions on Use and Disclosure
HIPAA Request to Review Amend Record
Innovations Periodic Codes Service Request Additon
Innovations Quarterly Progress Summary
Innovations Quarterly Progress Summary Instructions and Due Dates
ISP Short Term Goals Documentation
Level of Care Eligibility Determination Tool
Licensed Facility Rule Waiver Request Protocol
LME Consumer Admission and Discharge Form
Notice of Change
Payment Form
Provider Application Request
Provider Assignments to Credentialing Team
Provider Directory Update Form
Provider Request for Reconsideration of an Action Form
Provider Self Audit Submission Instructions
Provider Self Audit Templates
Record Destruction Log
Record Storage Log IPRS
Record Storage Log Medicaid
Relative as Provider Application Part A
Relative as Provider Application Part A and D Addendum
Relative as Provider Application Part A-1 (effective 11/1/16)
Request to Add Clinician
Sample ISP Short Term Goals Implementation
TCLV Special Claims Requisition Form
Universal Therapeutic Foster Care Application
Universal Treatment Foster Care and Residential Services Application
Unlicensed AFL Site Enrollment Request
Wage Complaint


Page last modified: June 26, 2017