Thank you for your interest in becoming an L.A. Care Health Plan network provider. All applicants are required to be Medi-Cal providers; this form is necessary to perform an initial assessment to confirm your eligibility for participation. Organization Name Legal Entity Name (as it appears on W-9) DBA Organization website Organization Practice Address Organization Practice Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Organization Phone Number Type - Type -HomeOfficeCell Phone Ext: Organization Fax Number Ancillary Provider Type Scope of Services Service Areas Tax Identification Number (TIN) National Provider Identification (NPI) Other Address Number of Locations in L.A. County (Provider must have a location in LA County) Languages Organization's Years of Experience Are you Medicare Certified? Yes No Are you Medicaid Certified? (Credentialing Requirement) Yes No Are you CLIA Certified? Yes No Are you Currently on the OIG exclusion list of DHCS suspended & ineligible list? Yes No Other Certifications Point of Contact Full Name Point of Contact Phone Number Type - Type -HomeOfficeCell Phone Ext: Point of Contact Email Address If you are submitting a Letter of Interest for more than one provider or location, please attach a Roster with the following information (Specialties, CAQH # (if applicable), Type 2 (Individual, NPI #, List Each Practitioner’s Locations and Days and Hours of Operation at Each Location Upload One file only.100 MB limit.Allowed types: jpg, jpeg, png, txt, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, zip. CAPTCHA Submit