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. The L.A. Care Direct Network is our directly contracted network. Physicians can see L.A. Care members without being affiliated with an IPA. At this time the L.A. Care Direct Network is for Medi-Cal only. All providers who apply for the Direct Network must be a Medi-Cal provider. Are you either an individual or group practice? Individual Group Practice Select if you are either PCP, Specialist, Both (Multi-specialty group) PCP Specialist Both (Multi-specialty group) Practice Name Office Administrator Full Name Office Administrator Phone Number Office Administrator Email Address Provider Name Requesting Individual (if different) Legal Entity Name (as it appears on W-9) Date Licensure DEA# Date of Birth (DOB) Specialties Primary Specialty Secondary Specialty Type of Provider (Midlevel, DO,MD) Number of Physicians Tax Identification Number (TIN) National Provider Identification (NPI) Practice Address for location(s) in Los Angeles County Other Address for location(s) in Los Angeles County Phone Number Fax Number Hospital Surgery Center (if applicable) Email Address Languages Certification (check all applicable boxes) Medicare Certified Medicaid Certified CLIA Certified Currently on the OIG exclusion list of DHCS suspended & ineligible list If you are submitting a Letter of Interest for more than one provider or location, please attach a Roster with the following information (Individual Practitioner Name, Degree (MD, DO, PA, NP, etc.), Specialties, Primary, Secondary, CAQH # (if applicable), Type I (Individual, NPI #, List Each Practitioner’s Locations and Days and Hours of Operation at Each Location. Roster Upload One file only.100 MB limit.Allowed types: jpg, jpeg, png, txt, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, zip. CAPTCHA Submit