Ancillary Form

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 Practice Address
Organization Phone Number
Are you Medicare Certified?
Are you Medicaid Certified? (Credentialing Requirement)
Are you CLIA Certified?
Are you Currently on the OIG exclusion list of DHCS suspended & ineligible list?
Point of Contact Phone Number
One file only.
100 MB limit.
Allowed types: jpg, jpeg, png, txt, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, zip.
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