Department of HealthThe role of case management 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the REQUEST DATE in MM/DD/YYYY format at the top of the form.
3. In SECTION 1, provide your REFERRING PROVIDER INFORMATION. Fill in your NAME, FACILITY/CLINIC NAME, PHONE NUMBER, and FAX NUMBER. Select your REFERRAL SOURCE from the options provided.
4. Move to SECTION 2 and enter ALLIANCE MEMBER INFORMATION. Include LAST NAME, FIRST NAME, ALLIANCE MEMBER ID #, DATE OF BIRTH, PHONE NUMBER, SEX (select either FEMALE or MALE), and ADDRESS details.
5. In SECTION 3, describe the REASON FOR REFERRAL. Ensure to attach any supporting clinical documents from the past 30 days as required.
6. Once all sections are completed, review your entries for accuracy before submitting via mail or fax as instructed.

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