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:

  Letter of Interest that outlines the following:
    1. What Specialty/Services your interested in contracting for
    2. Facility location(s)
    3. National Provider Identifier (for each facility)

  Ancillary Provider Network Participation Request Form

  UC Minimum Qualifications

  W-9 Form
    1. A current Taxpayer Identification Number and Certification form

  Liability Insurance Certificate
    1. Professional general liability in the minimum amount of One Million Dollars ($1,000,000) per occurrence; and
    2.  Three Million Dollars ($3,000,000) aggregate per year for professional liability.

  California State License
(for each facility)

  Provider Accreditation Certificate and/or CMS/DHCS Passing Site Survey or Approval letter

  Ownership Information
(Name/Title/% of Ownership)

Any delay in receiving the above stated documents will affect the effective date of the contract that will be mailed to you. If you have any questions or concerns please feel free to contact the IEHP Contracting Department at (909) 890-2954. Fax your completed information to (909) 890-2997.