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

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

  1. Vision 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
    • Medi-Cal Provider information number (PIN)
  3. W-9 Form 
    • A current Taxpayer Identification Number and Certification Form
  4. California Participating Physician Application
  5. 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.
  6. Facility Business License - Facility
  7. Ownership Information
    • Name, Title and Percent of Ownership

All documents should be e-mailed to