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.
Please completely fill out all required documents and submit to email@example.com
Any delay in receiving the below stated documents will affect the effective date of the contract that will be mailed to you.
- Vision Provider Network Participation Form
- 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
- Medi-Cal Provider information number (PIN)
- W-9 Form
- A current Taxpayer Identification Number and Certification Form
- California Participating Physician Application
- 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.
- Facility Business License - Facility
- Ownership Information
- Name, Title and Percent of Ownership
All documents should be e-mailed to firstname.lastname@example.org