Thank you for your interest in becoming a provider with the new Community Health Worker Medi-Cal Benefit with L.A. Care. To become a CHW Benefit Provider, your organization must be able to provide the following services:Health EducationHealth Navigation Individual Support and Advocacy Screening and Assessment Violence Prevention Services The completion and response to the following questions is necessary to perform an initial assessment to confirm your eligibility for participation in this program. Organization Name Legal Entity Name Tax Identification Number (TIN) National Provider Identification Organization Website Type of Organization Community Based Organization Specialty Mental Health, Behavioral health or Substance Use Treatment Center Community Health Center, FQHC, Rural Health Center, Indian Health Clinic/Center Hospital/Hospital-Based Physician Group Community Based Primary Care or Specialty Physician Local Government Entity Other… Enter other… CHW Benefit Point of Contact and Title CHW Benefit Point of Contact Phone Type - Type -HomeOfficeCell Phone Ext: CHW Benefit Point of Contact Email Are you currently contracted with L.A. Care? Yes No Which program are you contracted for? Contracting Point of Contact and Title Contracting Point of Contact Phone Type - Type -HomeOfficeCell Phone Ext: Contracting Point of Contact Email Which Service Planning Area (SPAs) would you cover? SPA 1: Antelope Valley SPA 2: San Fernando SPA 3: San Gabriel SPA 4: Metro LA SPA 5: West LA SPA 6: South LA SPA 7: East LA SPA 8: South Bay Can your agency provide all of the below services per the CHW ALL Plan Letter (including Health Education, Health Navigation, Individual Support and Advocacy, Screening and Assessment, and Violence Prevention Services? Yes No How many CHW workers do you currently employ? How many of your CHWs require certification training? Do you require financial assistance? Yes No Do you plan to subcontract services under the CHW Benefit? Yes No Are you currently Medi-Cal enrolled through PAVE? Yes No Should you have any questions please reach out to CHWBenefit_NetworkInquiries@lacare.org CAPTCHA Submit