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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.

 

The contract collateral and other supporting contract documents should be e-mailed to jointhenetwork@iehp.org.

 

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

 

Providers must also successfully enroll in the state’s Medi-Cal Program to be issued a Medi-Cal number.

Medi-Cal Screening and Enrollment

 

Visit the following page for more information on the Medi-Cal Program. 

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Contracting Requirements – New Contract

  • Completed Letter of Interest (LOI) Form
  • W-9 Form
  • Proof of Medi-Cal enrollment or proof of Medi-Cal application submission. Please refer to our Screening and Enrollment page for additional information. 

Contracting Requirements – Existing Contract (Adding New Provider)

  • Medi-Cal Number
  • Physician and Specialists Form (M.D., D.O., D.P.M., D.C., O.D., S.P., AuD., P.T., etc)
  • Mid-Level Practitioners Form (P.A., N.P., and C.N.M.)
  • Supervisor Agreement Form (Only applies to Physician Assistants)
  • Pre-Contractual Letter Form (Only applies to PCPs. Please review and return signed if all outlined criteria is met)

Additional Resources:

 

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.