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. Name of Provider(s) on contract
    4. Medical License for Provider(s)
    5. National Provider Identifier (for facility and providers)
    6. Liability Insurance Certificate

  Physician Network Participation Request Form

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

  California Participating Physician Application
    1. CPPA
(One CPPA completed for each provider listed on the contract)
    2. Addendums (A,B, & C)
   
  Pre-Contractual Letter
(Only applies to PCPs)
Please review the above Pre-Contractual letter and return signed if all outlined criteria is met.
    1. Primary Specialty
    2. Secondary Specialty
    3. Age Range
    4. Hospital Privileges
    5. Name of Hospital(s)
    6. If no Hospital Admitting Privileges, who Admits for PCP

  Supervisor Agreement
(Only applies to Physician Assistants)

  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.