Contact Us
Find a Doctor
I Am
An Employer
Insights
Information & Resources
Membership Benefits
Contact Us
A Broker
Insights
Information & Resources
Contact Us
A TPA
Contact Us
Information & Resources
A Provider
Information & Resources
Provider Forms
Claims Portal
Contact Us
An Employee or Family Member
Information & Resources
Contact Us
Self-Funding Options
How to Self-Fund Smart
Self-Funding with The Alliance
®
ASO Health Plans
Taking the Next Step to Self-Fund
What We Offer
Smarter Networks
SM
: Custom Provider Networks
Smarter Health
SM
Analysis
Steerage
Advanced Primary Care
Who We Are
Mission & Vision
People
Careers
Insights & Resources
Blog
Case Studies
Health Policy
Newsletters
The Alliance Newsroom
Events
Events by The Alliance
Event Sponsorship Program
Information & Resources
Contact Us
Find a Doctor
M
Find a Doctor
Contact Us
I Am
An Employer
Insights
Information & Resources
Membership Benefits
Contact Us
A Broker
Insights
Information & Resources
Contact Us
A TPA
Contact Us
Information & Resources
A Provider
Information & Resources
Provider Forms
Claims Portal
Contact Us
An Employee or Family Member
Information & Resources
Contact Us
Self-Funding Options
How to Self-Fund Smart
Self-Funding with The Alliance
®
ASO Health Plans
Taking the Next Step
What We Offer
Smarter Networks
SM
: Custom Provider Networks
Smarter Health
SM
Analysis
Steerage
Advanced Primary Care
Who We Are
Mission & Vision
People
Careers
Insights & Resources
Blog
Case Studies
Health Policy
Newsletters
The Alliance Newsroom
Events
Events by The Alliance
Event Sponsorship Program
Contact - Tricia Newton
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Mark Bennehoff
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Jennifer Austin
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Vicki Movrich
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Jill Hamus
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Name
First
Last
Comments
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Theresa Islo
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Doug Benzine
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
CLOSE
Mike Roche, Director of Business Development at The Alliance
Name
(Required)
First
Last
Email
(Required)
Organization
Message
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
CLOSE
Contact Mike Roche, Director of Business Development at The Alliance
Name
(Required)
First
Last
Email
(Required)
Organization
Message
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Bobbie Jo Aue
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
CLOSE
New Provider Contract Intake Form
Legal Name of Practice
(Required)
Doing Business As
(if applicable)
Tax ID
Primary Street Address
(Required)
Address Line 2
City
(Required)
State / Province / Region
(Required)
ZIP / Postal Code
(Required)
Country
(Required)
Phone
Website
Number of Practitioners
Please enter a number greater than or equal to
1
.
Specialty
Are you currently providing services to members of The Alliance?
Yes
No
Contact Person (for contract negotiation)
First Name
Last Name
Title
Email
(Required)
Phone
Contact Person (for formal notices)
First Name
Last Name
Title
Email
(Required)
Phone
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
CLOSE
New Provider Contract Intake Form
Legal Name of Practice
(Required)
Doing Business As
(if applicable)
Tax ID
Primary Street Address
(Required)
Address Line 2
City
(Required)
State / Province / Region
(Required)
ZIP / Postal Code
(Required)
Country
(Required)
Phone
Website
Number of Practitioners
Please enter a number greater than or equal to
1
.
Specialty
Are you currently providing services to members of The Alliance?
Yes
No
Contact Person (for contract negotiation)
First Name
Last Name
Title
Email
(Required)
Phone
Contact Person (for formal notices)
First Name
Last Name
Title
Email
(Required)
Phone
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Melina Kambitsi
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
CLOSE
CLOSE
Contact - Paul Roelke
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Cheryl DeMars
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Mike Roche
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Jess Robinson
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Jess Ellefson
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Holly Dooley
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
CLOSE
Contact - Debora Kunferman
Send a Message:
Message
From:
Name
(Required)
First
Last
Organization
Email
(Required)
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
CLOSE
CLOSE
CLOSE
