Thank you for your interest in becoming an L.A. Care Health Plan network provider. This form is necessary to perform an initial assessment to confirm your eligibility for participation. Facility Name Legal Entity Name (as it appears on W-9) Facility Website URL Facility Physical Address Facility Phone Number Facility Fax Number Specialized Services Tax Identification Number (TIN) National Provider Identification (NPI) Other Address Languages # of L.A. Care members currently servicing and members line of business Certification (check all applicable boxes) Medicare Certified Medicaid Certified CLIA Certified Currently on the OIG exclusion list of DHCS suspended & ineligible list Other Certifications Point of Contact Full Name Point of Contact Phone Number Point of Contact Email Address CAPTCHA Submit