We’re glad you’re here.

Discover a health care partner with the compassion to see your unique needs and the competence to meet them.

Information on Alliance Services

Take the first step, and we'll walk together from there.

Thank you for considering Alliance Health Care. Whether you’re seeking care for yourself, for a loved one, or on behalf of a client, please fill out the Referral Form to get started. Each field of information helps us to identify the healthcare services that will best meet your unique needs and preferences.

Need help filling out the form? Give us a call and we’d be glad to help.

Referral Form

Services Interested In:

Please select:

Waiver Type:

County of Financial Responsibility:

What services do you need?

What services is desired?

How often do you need services?

Staff First Name

Staff Last Name

Staff Email

Staff Phone Number

Current Clinic Name

Current Clinic Phone Number:

Clinic Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

What supplies are you looking for?

Client Information:

Full Name for Insurance:

Date of Referral:

Correct Name:

Date of Birth:

Client's Email:

Anticipated Start of Care Date:

Current Clinic Name

Pronouns:

Client's Phone Number:

Authorized Representative, Responsible Party or Guardian Information:

Address Line 1:

Address Line 2:

City:

State:

Zip Code

Country

I give you authorization to email and text the address and number I have provided on this form.

Yes

Address Line 1:

Address Line 2:

City:

State:

Zip Code

Country

Should we contact the authorized rep instead of client?

Yes

Referring Person:

First Name:

Last Name:

Email:

Phone Number:

Insurance Number/ Group Number/ Insurance Provider/ MA number:

Allergies:

Do you:

Have pets?

Smoke?

Need an Interpreter?

Primary Care Doctor:

Primary Care Doctor Name

Name of Clinic:

Email:

Phone Number:

Diagnosis Code (if known)

Case Worker / Social Worker:

Case Manager / Social Worker name

Name of Agency:

Email:

Phone Number:

Emergency Person:

First Name:

Last Name:

Email:

Phone Number:

Alliance might have started as a Personal Care Agency, but we’ve grown since starting in 1990. Today, we’ve got the capacity to connect you to all the care you need. Whether it’s mental health services at our office, connecting you to home care, meeting your financial management service needs, bringing the medical supply marketplace to you, or anything in-between, Alliance is here to walk you through every step of the process.

Let's Get You Started.

We make getting connected to Alliance simple so you can get the care you need to live the life you want.

We’re glad you’re here.

Information on Alliance Services

Take the first step, and we'll walk together from there.

Let's Get You Started.

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