Thank you for your initial interest in becoming an Inland Empire Health Plan (IEHP) directly contracted provider. Prior to extending a contract, we must receive the following documents:

  1. DME Provider Network Participation Form
  2. Letter of Interest that outlines the following:
    • What Specialty/Services your interested in contracting for
    • Facility location(s)
    • National Provider Identifier (NPI) for each facility
  3. W-9 Form 
    • A current Taxpayer Identification Number and Certification Form
  4. Liability Insurance Certificate
    • Professional general liability in the minimum amount of One Million Dollars ($1,000,000) per occurrence; and
    • Three Million Dollars ($3,000,000) aggregate per year for professional liability.
  5. Facility Business License - Facility
  6. Ownership Information
    • Name, Title and Percent of Ownership
    • Articles of Incorporation new Effective 09/01/13
      • Certified, stamped copy issued by the Secretary of State
      • Applies to Corporations, LLC and Non-Profits only
    • Fictitious Business Name Receiptnew Effective 09/01/13
      • Certified, stamped copy issued by the County
      • Applies to Sole Proprietors only
  7. Documentation required to provide services to Medicare Members for DME providers:
    • Accreditation certificate
    • Approval letter from the Centers from Medicare and Medicaid (CMS)
    • Copy of surety bond for each facility as required by CMS

Any delay in receiving the above stated documents will affect the effective date of the contract that will be mailed to you. 

The contract collateral and other supporting contract documents should be e-mailed to 

The credentialing application and relevant document should be e-mailed to