PCP and Specialists
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.
Any delay in receiving the below stated documents will affect the effective date of the contract that will be mailed to you.
| Existing Contract
(Adding New Provider)
- Physicians and Specialists (M.D., D.O., D.P.M., D.C., O.D., S.P., AuD., P.T., etc)
- Pre-Contractual Letter (Only applies to PCPs. Please review and return signed if all outlined criteria is met)
- Mid Level Practitioners (P.A., N.P., and C.N.M.)
- Supervisor Agreement (Only Applies to Physician Assistants)
|All documents should be e-mailed to email@example.com
|| All documents should be e-mailed to firstname.lastname@example.org
- Individual W-9 and Participation Request forms can be found here