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/Facility 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) Tax Identification Number (TIN) National Provider Identification (NPI) Licensure DEA# Date of Birth (DOB) Specialties Primary Specialty Secondary Specialty Provider Type (Midlevel, DO,MD) Behavioral Health Plastic Surgery OB/GYN Otolaryngology/ENT Urology Electrolysis Other If other, please specify Number of physicians within practice wishing to be contracted for Transgender Health Services Services/Procedures Provided Length of time providing services for Transgender Community Panel Size Membership Practice Address Other Address Practice Phone Number Practice Fax Number Hospital and Surgery Center Privileges Provider Email Languages Years of Experience in Private Practice Certification (check all applicable boxes) Medicare Certified Medicaid Certified CLIA Certified Currently on the OIG exclusion list of DHCS suspended & ineligible list Cultural Sensitivity for LGBTQ+ Communities 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 Specialty, Secondary Specialty, CAQH # (if applicable), Type I (Individual) NPI #, and Each Practitioner’s Locations and Days and Hours of Operation at Each Location. Upload Roster? CAPTCHA Submit