Member Appointment No-Show Notification

Please fax this form to Provider Services at: (831) 430-5857 Please fill in all applicable spaces Member’s Name: Appt Date: ALLIANCE ID#: DOB: Member Phone #: Type of Appointment: Well Child / Physician Exam / Annual Follow-Up Routine Office Visit Ill Immunizations New Patient Consult Post-Partum Prescription Blood Pressure Check F/U on Pregnancy Other: Was Member reminded of appointment by: mail Yes No or phone? Yes No What have you done to follow-up with the patient?

Provider Name: Fax #: Provider Staff Person Contact: Date:

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ALLIANCE FOLLOW-UP Member Service Representative (MSR) reports: Did you make contact by phone? Yes No LM/VM Wrong # No Answer If no contact by phone, was letter sent? Yes No Date Sent: Comments:

MSR Name: Date rec’d: Date completed:

CREATING HEALTHCARE SOLUTIONS Form: CCAH 1010 MNS (Revised 07/2009)