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. Group Name Legal Entity Name (as it appears on W-9) Tax Identification Number (TIN) National Provider Identification (NPI) Group Website URL Group Practice Address Group Phone Number Group Fax Number Total Membership Primary Hospitals & Surgery Centers Other Contracted Health Plans Products currently contracted for Network includes all 29 Specialties required by DMHC Hospital and Surgery Center privileges Point of Contact Full Name Point of Contact Phone Number Point of Contact Email Address Management Services Organization (MSO) CAPTCHA Submit