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  • Alameda Care Management Programs Referral Form 2013

Get Alameda Care Management Programs Referral Form 2013

NS: 1) Print clearly in blue or black ink. 2) Fax or mail original form to the number or address above. Note: The member will be notified directly if they are selected for one of the programs. A. REFERRING PROVIDER INFORMATION REQUEST DATE: SUBMITTED BY: CONTACT PHONE #: FACILITY/CLINIC: FAX: REFERRAL SOURCE: Hospital PCP Specialty Provider Community Partner B. MEMBER INFORMATION MEMBER NAME: DATE OF BIRTH: ADDRESS & CITY: AGE: SEX: ZIP: MEMBER PHONE # (HOME OR CELL.

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Contact support

1-800-491-9099 Alameda County Behavioral Health Care Services' (ACBHCS) ACCESS Program is the system wide point of contact for information, screening and referrals for mental health and substance use services and treatment for Alameda County residents.

If you have questions, call 1-800-464-4000 (TTY 711). We are here 24 hours a day, 7 days a week (except closed holidays).

To apply for Medi-Cal by mail, you can send your Medi-Cal application to an Alameda County Social Services Agency office. To request a Medi-Cal application to mail in and Instructions booklet, please call (510) 272-3663 or 1-800-698-1118 (toll free).

You can also call the Alliance Provider Services Department at 1.510. 747.4510.

1 to 23 of 23Department/ServicePhone NumberPhone NumberMedi-Cal Information - SSA(800) 698-1118(510) 577-3547Program Integrity Division - SSA(510) 383-8777(510) 577-1900Program Intregrity Division - SSA(510) 383-8777(888) 999-477210 more rows

The Alliance currently provides health care coverage to over 300,000 children and adults through their programs: Medi-Cal and Alliance Group Care.

REASON FOR REFERRAL (please attach supporting/clinical documents from the past 30 days): For behavioral health referrals, please call Beacon toll-free at 1.855. 856.0577.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Alameda Care Management Programs Referral Form
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