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Click ‘Get Form’ to open the California Alameda Alliance Health Medication Request Form in the editor.
Begin by filling in the 'Patient Name' and 'Patient DOB' fields. Ensure accuracy as this information is crucial for identification.
Enter the 'Patient ID Number', followed by the 'Prescriber Name', 'Specialty', and contact details including 'Prescriber Phone' and 'Fax'.
Provide the 'NPI#' and 'Prescriber Address'. Next, fill in the pharmacy details: 'Pharmacy Name', 'Phone', and 'Fax'.
In the medication section, specify the 'Medication Name and Strength Requested'. If applicable, check the box for a Brand Medically Necessary request and provide rationale.
Indicate the 'Quantity Requested' and select the anticipated length of therapy (Days, 3 Months, 6 Months, or 12 Months).
Document the diagnosis and list any preferred medications tried along with their strength, frequency, and duration.
Finally, provide any additional information relevant to your request in the rationale section. Don’t forget to sign and date at the bottom before submission.

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What insurance provider is Medi-Cal?

Medi-Cal is Californias Medicaid program, designed to help low-income individuals and families gain access to necessary medical and health care providers and services. The California Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS) oversee the program.

What is another name for Medi-Cal insurance?

Medi-Cal is Medicaid for California. It offers free or low-cost health coverage to people who qualify.

Is Ccah the same as Medi-Cal?

You can select the Alliance as your health plan on your Medi-Cal Choice Form if: You have Medi-Cal. You are eligible to be in a managed care health plan. You live in Alameda County.

Is Alameda Alliance the same as Medi-Cal?

Q: What is the Alameda Alliance For Health (AAH) Medicare Advantage (MA) Dual Eligible Special Needs Plan (D-SNP)? A: The new plan will serve Alameda County residents who are eligible for both Medicare and Medi- Cal benefits (Dual Eligibles).

Is Alameda Alliance Medicare or Medicaid?

Medi-Cal is Californias Medicaid health care program that provides no-cost or low-cost health insurance to Californians. Central California Alliance for Health (the Alliance) is a managed care health plan for people who have Medi-Cal.

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