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 Address
    3. Mailing Address and attention to whom
    4. Phone numbers and fax numbers
    5. Business Hours
    6. Provider(s) Names & License #
    7. National Provider Identifier (for each facility)

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

  Ownership Information 
(Name/Title/% of Ownership)

Thank you for your time.  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.