Alliance Holistic Health Network Provider Nomination



		Providing Benefits for Groups and Individuals since 1985



	Alliance Holistic Health Network Provider Nomination Form

Please Note: All areas must be completed in order to receive a response. If you need
any assistance, please contact us: Alternative Health Insurance Services

I hereby request that the following medical provider be contracted to become a contracted/preferred provider with Alliance Holistic Health Network


	Name of Provider:

	Medical Specialty:


	Address Line1:


	Address Line2:


	City:


	State:


	Phone Number:


	Fax Number:


	Email Address:


	Zip Code:

Referred By:

Your Name:


	Address Line1:


	Address Line2:


	City:


	Phone Number:


	State:


	Zip Code:

Following receipt of this request form, the Alliance will send contracting information to qualified provider(s) and rely on the provider to respond if interested. In order to expedite contracting efforts, the requesting party (you) should follow up with the nominated provider to obtain participation status. The Alliance will do its best to provide members with current information regarding contracted providers, however, you should check with your provider(s) for any updates on participating status.

Completion of this nominating form does not guarantee inclusion in the preferred provider network.

In order to participate in the preferred provider network, each provider is required to provide discounts on their fees which are sufficient for the program to offer satisfactory levels of benefits for participating members.

The provider should receive new patients as a result of being listed as a preferred provider. The member (you) benefit with lower out-of-pocket costs than would normally be required when using non-contracted providers


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	Alternative Health Insurance Services 117 Bernal Road # 70-205 San Jose, CA 95119 Phone: (408) 223-1787 Fax: (208) 567-2507


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